Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
NOT FOR PROFIT AGENCY CERTIFICATION <br /> The County of Indian River requires , as a matter of policy, that any Consultant or firm receiving a <br /> contract or award resulting from the Request for Qualifications issued by the County of Indian <br /> River, Florida , shall make certification as below. Receipt of such certification , under oath , shall <br /> be a prerequisite to the award of contract and payment thereof. <br /> 1 (we ) hereby certify that if the contract is awarded to me , our firm , partnership , or corporation , <br /> that no members of the elected governing body of Indian River County, nor any professional <br /> management, administrative official or employee of the County, nor members of his or her <br /> immediate family, including spouse , parents , or children , nor any person representing or <br /> purporting to represent any member or members of the elected governing body or other official , <br /> has solicited , has received or has been promised , directly or indirectly, any financial benefit , <br /> including but not limited to a fee , commission , finder's fee , political contribution , goods or services <br /> in return for favorable review of any Proposal submitted in response to the Request for <br /> Qualifications or in return for execution of a contract for performance or provision of services for <br /> which Proposals are herein sought . <br /> The undersigned certifies that he/she is a principal or officer of the firm applying for consideration <br /> and is authorized to make the above acknowledgments and certifications for and on behalf of the <br /> applicant . <br /> The undersigned certifies that the Applicant has not been convicted of a public entity crime within <br /> 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 : Q3 <br /> NAME : <br /> TITLE : Cf,(, <br /> NAME OF FIRM/PARTNERSHIP/CORPORATION : <br /> FOR AND ON BEHALF OF THE APPLICANT: <br /> Sworn to and subscribed to <br /> me , a Notary Public , this ' I <br /> day of , 2003 . BYr , <br /> (SEAL) (TYPE NAME & TITLE ) <br /> 1*a Pie FAY H. PRADO <br /> a° ' c MY COMMISSION ADD 126400 <br /> EXPIRES: June 16, 2006 <br /> ��rEavd�° eawaa raw Budget rmwv Services <br /> X <br />