_____________________________________
Date
_____________________________________
Date
1. Witness
__________________________________________
Signature (digital signatures not accepted)
__________________________________________
Print Name
2. Witness
__________________________________________
Signature (digital signatures not accepted)
__________________________________________
Print Name
APPLICANT CERTIFICATION AND SIGNATURES (Verified Application)
The submitted Application, including attachments, is subject to disclosure under Florida’s public records law subject to
limited applicable exemptions. Applicant acknowledges, understands, and agrees that, except as noted below, all
information in its application and attachments will be disclosed, without any notice to Applicant, if a public records
request is made for such information, and the County will not be liable to Applicant for such disclosure.
• Social security numbers that are collected, maintained and reported by the County must comply with IRS 1099
reporting requirements and are exempt from public records pursuant to Florida Statutes §119.071.
• If Applicant believes that information in its application, including attachments, contains information that is
confidential and exempt from disclosure, Applicant must include a general description of the information and
provide reference to the Florida statute or other law which exempts such designated information from disclosure in
the event a public records request is made. The County does not warrant or guarantee that information designated
by Applicant as exempt from disclosure is in fact exempt, and if the County disagrees, it will make such disclosures in
accordance with its sole determination as to the applicable law.
I certify that, I am authorized to submit this application on behalf of the business, the information provided in this
application is true and accurate to the best of my ability, and no false or misleading statements have been made in order
to secure approval of this application. You are authorized to make all the inquiries you deem necessary to verify the
accuracy of the information contained herein. Additionally, applicant agrees that if money is provided pursuant to this
application, the County or its agent shall be entitled to access and audit such records as may be necessary to prevent
fraud in this process or ensure compliance with federal requirements.
Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in it are true. I
understand that knowingly making a false written declaration may be charged as a felony of the third degree.
____________________________________
Date
____________________________________
Company
_____________________________________________
Applicant Signature (digital signatures not accepted)
_____________________________________________
Print Name
_____________________________________________
Applicant Title
Witnesses (two witness signatures are required)
