Laserfiche WebLink
The entity submitting this sworn statement , or one or more of the officers , directors , <br /> executives , partners , shareholders , employees , members , or agents who are active <br /> in management of the entity have the following relationships with a County <br /> Commissioner or County employee : <br /> Name of Affiliate Name of County Relationship <br /> or Entity Commissioner or employee <br /> 2 - <br /> 3 - <br /> 4. <br /> .3 .4. <br /> 5 . <br /> 6. <br /> . <br /> 8 <br /> 8 . <br /> (signature) <br /> 11122 /0 <br /> (date) <br /> STATE OF <br /> COUNTY OF _p Ct non c� <br /> Personally appeared before me , the undersigned authority, Se r'� tl fl >.,$ A t <br /> who after first being sworn by me , affixed his/her signature in the space provided above on this <br /> Z of <br /> NOTARY PUB 'C- TATE OF FLORIDA <br /> :_ Comm; <br /> he Brown <br /> on #DD833968 <br /> Notary q10611ic, State at IarW .•�` FxPires: OCT. 26, 2012 <br /> s en ruao A't'LAN77cBotrnurc ca, utc <br /> My Co mission Expires : <br /> END OF SECTION <br /> P:\Engineering\Capital Projects\9920- 16th St, 74th Ave to 66th Ave\9920 Contract Documents & Specs\00452 Disclosure of Relationships.doc <br /> 00452-2 <br />