141-25 Exhibit.pdf

‘ I i i I | ' i I | contalned heretn and thet }am under a continulng odligation from the date of this certification through the completion of any contracts with Township of West Orange to notify the Township of West Orange in writing of any changes to the information contained hereln; that | am aware that tt Is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, | am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement{s) with the, permitting the Township of West Orange to declare any contract(s) resulting from this certification vold and unenforceable. Full Name (Print): . Title: Signature: Date: i i ‘ ! 1 | if Page [22