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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: <br /> NAME: <br /> TITLE: Xr 0-. <br /> NAME OF F,IIR;M/PARTNERSHIP/CORPORATION : ^ Wit`; <br /> FOR AND ON BEHALF OF THE APPLICANT: <br /> Sworn to and subscribed to <br /> Notary Public, this <br /> day of , 2006. BY: <br /> (SEAL) (TYPE NAME & TITLE) <br /> � . fflf�l <br /> Y f�1M - Ilab Of Rodda <br /> Bpw�M3V17.11b7 <br /> CaftlTWbn Y DDI 94076 <br /> Bwxi,d fiy Nntbr d Notary Asan <br /> XI <br />