1. DISCLOSURE STATEMENT
    1. State of Florida, Department of Education
 
DISCLOSURE STATEMENT


State of Florida, Department of Education

Contract No.       

 

 
Contractor represents and warrants as a material inducement to the State of Florida, Department of Education (“Department”), to enter the above referenced Contract that:
   
1. Neither Contractor, nor any officer, agent or employee of Contractor has now or ever has had any private business venture with the following individuals (hereinafter called “Agency Personnel”): Members of the State Board of Education, the Board of Governors, the Commissioner of Education, the Contract Manager named in the Contract, or the members of the Senior Management Service or Selected Exempt Service presently employed by Department or the State Board of Education; and
2. Neither Contractor, nor any officer, agent or employee of Contractor has given or offered to give money or anything else of value to any one or more of the Agency Personnel, or to any other person, in consideration for Contractor’s selection as Contractor; and
3. Contractor knows of no fact or incidence of wrongdoing surrounding its selection as Contractor that, if disclosed to the Department would call into question Contractor’s selection as Contractor or its fitness or ability to meet all of its legal and ethical obligations under the Contract.
 
     
Name of Contractor
Signature
(If Corporation, Partnership or D/B/A):

                                   Title

 

       
Address
Phone/ Fax
    
Sworn to and subscribed before me this ____ day of ______________, ____, by
____________________________________________, who is personally known to me or who produced
_______________________________ for identification.
 
  
__________________________________________
Signature of Notary Public
__________________________________________
Name of Notary Public
My Commission expires:

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Form OGC-CM 08   Page 1 of 1  

Last revised September 11, 2003