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NOT FOR PROFIT AGENCY CERTIFICATION <br /> The County of Indian River requires, as a matter of policy, that any Consultant or firm <br /> receiving a contract or award resulting from the Request for Qualifications issued by the <br /> County of Indian River, Florida, shall make certification as below. Receipt of such <br /> certification , under oath , shall be a prerequisite to the award of contract and payment <br /> thereof. <br /> I (we) hereby certify that if the contract is awarded to me , our firm , partnership , or <br /> corporation , that no members of the elected governing body of Indian River County, nor <br /> any professional management, administrative official or employee of the County, nor <br /> members of his or her immediate family, including spouse, parents , or children , nor any <br /> person representing or purporting to represent any member or members of the elected <br /> governing body or other official , has solicited , has received or has been promised , <br /> directly or indirectly, any financial benefit, including but not limited to a fee, commission , <br /> finder's fee, political contribution , goods or services in return for favorable review of any <br /> Proposal submitted in response to the Request for Qualifications or in return for <br /> execution of a contract for performance or provision of services for which Proposals are <br /> herein sought. <br /> The undersigned certifies that he/she is a principal or officer of the firm applying for <br /> consideration and is authorized to make the above acknowledgments and certifications <br /> for and on behalf of the applicant. <br /> The undersigned certifies that the Applicant has not been convicted of a public entity <br /> crime within the past 36 months, as set forth in Section 287. 133 , Florida Statutes. <br /> Failure to sign this form will result in disqualification. _ <br /> Handwritten Signature of Authorized Principal(s): DATE: c1 <br /> t <br /> NAME : \ l - 0 <br /> TITLE: - <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : t ' LO - V6 . A - . <br /> FOR AND ON BEHALF OF THE APPLICANT: <br /> Sworn to and subscribed to <br /> me, a Notary Public, this <br /> c33rd day of 12006 . BY: <br /> (SEAL) (TYPE NAME & TITLE) <br /> hbk • NO& of HoAda <br /> WRoled <br /> 17,20D7 <br /> n*WOn I DD194076 <br /> By Nolio K0 Nofo yAW, . <br /> XI <br />