Taylor County RSOQ

Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
TAYLOR COUNTY, FLORIDA
| BOARD OF COUNTY COMMISSIONERS
REQUEST FOR STATEMENTS OF
QUALIFICATIONS
HMGP STORMWATER ENGINEERING DESIGN SERVICES
PROJECT 1 PROJECT 2 PROJECT 3 PROJECT 4
Foley Cut Off Road East Ellison Road - Dewey McGuire Wilder Creek -
- Flood Risk Flood Risk Road - Flood Risk Flood Risk
Reduction Reduction Reduction Reduction
HMGP Project No. 4734- HMGP Project No. 4734- HMGP Project No. 4734- HMGP Project No. 4734-
138-R 135-R 136-R 137-R
FDEM Contracts H1269 FDEM Contracts H1267 FDEM Contracts H1274 FDEM Contracts H1346
(HMGP) | H1270 (State (HMGP) | H1272 (State (HMGP) | H1275 (State (HMGP) | H1419 (State
Match) Match) Match) Match)
Issued by: Taylor County Board of County Commissioners | 201 East Green Street, Perry, Florida 32347
Taylor County is an Equal Opportunity Employer. These solicitations are subject to FEMA Hazard Mitigation Grant Program
requirements and 2 CFR Part 200 Uniform Guidance. Selection will be made on the basis of qualifications, not price. Fees will
be negotiated with the top-ranked firm.
This Request for Statements of Qualifications is issued by Taylor County in connection with four HMGP projects funded
through FEMA under Disaster Declaration DR-4734 (Hurricane Idalia) and administered by the Florida Division of Emergency
Management.
Taylor County Board of County Commissioners | Perry, Florida Page 1 of 15

Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
NOTICE
Request for Statements of Qualifications
HMGP Stormwater Engineering Design Services
Taylor County, Florida
Taylor County Board of County Commissioners hereby solicits Statements of Qualifications from qualified
professional engineering firms to provide Phase I HMGP engineering design services for the four projects
described herein, funded through the FEMA Hazard Mitigation Grant Program under Disaster Declaration DR-
4734 (Hurricane Idalia).
Sealed SOQ labeled: "HMGP STORMWATER ENGINEERING DESIGN SERVICES - FOLEY CUT OFF
ROAD, EAST ELLISON ROAD, DEWEY McGUIRE ROAD & WILDER CREEK - DO NOT OPEN"
Submit to:
Taylor County Clerk of Courts
108 N Jefferson Street
Perry, Florida 32347
SOQ Due: August 14, 2026 at 4:00 P.M. (Local Time)
Submittals Required: 1 original, 4 copies
This procurement is subject to FEMA Hazard Mitigation Grant Program requirements and 2 CFR Part 200 Uniform Guidance.
Taylor County is an Equal Opportunity Employer; consistent with Executive Order 14173, all federally funded procurement and
employment actions shall be identity-neutral and merit-based. RSOQ documents may also be obtained from
www.taylorcountygov.com.
SOQs will be opened and respondents announced at 6:05 P.M. (Local Time), or as soon thereafter as practical,
on August 18, 2026, at the Taylor County Administrative Complex, 201 East Green Street, Perry, Florida 32347.
ALL SOQs must have the respondent's name and mailing address clearly shown on the outside of the envelope
or package when submitted. NO FAXED SOQs WILL BE ACCEPTED.
The County reserves the right, in its sole and absolute discretion, to reject any or all SOQs, to cancel or withdraw
this Request for SOQs at any time, or to waive any irregularities in the SOQ process. The County reserves the
right to award any contract(s) to the Respondent which it deems to offer the best overall service. The County, in
its sole and absolute discretion, also reserves the right to waive minor defects in the process and to accept the
SOQ deemed to be in the County's best interest.
DBE/MBE/WBE and Service-Disabled Veteran Business Enterprise owned businesses are encouraged to submit
if qualified.
Additional information may be obtained from LaWanda Pemberton, lpemberton@taylorcountygov.com.
BY ORDER OF THE BOARD OF COUNTY COMMISSIONERS, Taylor County, Florida
Taylor County Board of County Commissioners | Perry, Florida Page 2 of 15

Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
SECTION 1 - INTRODUCTION & PROJECT OVERVIEW
Taylor County, Florida (the "County") invites qualified engineering firms or teams to submit Statements of
Qualifications (SOQ) for professional engineering services in connection with four HMGP Phase I projects, all
funded through the Federal Emergency Management Agency (FEMA) Hazard Mitigation Grant Program (HMGP)
under Disaster Declaration DR-4734 (Hurricane Idalia) and administered by the Florida Division of Emergency
Management (FDEM).
1.1 Issuing Authority
Taylor County Board of County Commissioners
201 East Green Street | Perry, Florida 32347
www.taylorcountygov.com
1.2 Project Descriptions
Project 1: Foley Cut Off Road Flood Risk Reduction
HMGP Project No. 4734-138-R | FDEM Contracts H1269 (HMGP) & H1270 (State Match)
The Foley Cut Off Road area is a low-lying rural area in Perry, Florida (approximate coordinates: 30.073 degreesN,
83.537 degreesW) that is repeatedly inundated by stormwater runoff. The area lacks a natural conveyance system to
allow water to flow out, causing flooding of homes and roads. The Phase II proposed scope of work includes
construction of two (2) 4-foot bottom width open conveyance swales - one along Foley Cut Off Road and one
along Foley Cut Off Road through private property - and an 18-inch concrete culvert along Eustis Gunter Road,
and a 24-inch concrete culvert along Foley Cut Off Road. These improvements are designed to protect against a
50-year storm event and address the lack of capacity in the existing conveyance systems.
Phase I scope of work includes but is not limited to:
Surveying, geotechnical investigation, and site assessment
Engineering design for swales, culverts, and related infrastructure
Plans preparation, specifications, and contract documents
Permitting with applicable state and local regulatory agencies
Bidding support
Phase II application deliverables for FDEM/FEMA review
Project 2: East Ellison Road Flood Risk Reduction
HMGP Project No. 4734-135-R | FDEM Contracts H1267 (HMGP) & H1272 (State Match)
The East Ellison Road project addresses flood risk reduction in a Taylor County area subject to recurring
stormwater inundation. Improvements will address deficiencies in the existing stormwater collection, conveyance,
and retention system consistent with HMGP Phase II requirements. The project is designed to provide protection
against a 50-year storm event and shall be completed in strict compliance with applicable Federal, State, and
local rules and regulations.
Phase I scope of work includes but is not limited to:
Surveying, geotechnical investigation, and site assessment
Hydrologic and hydraulic analysis
Engineering design of drainage improvements
Plans preparation, specifications, and contract documents
Permitting with applicable state and local regulatory agencies
Bidding support
Phase II application deliverables for FDEM/FEMA review
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Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
Project 3: Dewey McGuire Road Flood Risk Reduction
HMGP Project No. 4734-136-R | FDEM Contracts H1274 (HMGP) & H1275 (State Match)
The Dewey McGuire Road project addresses flood risk reduction in a Taylor County area subject to recurring
stormwater inundation. Improvements will address deficiencies in the existing stormwater collection, conveyance,
and retention system consistent with HMGP Phase II requirements. The project is designed to provide protection
against a 50-year storm event and shall be completed in strict compliance with applicable Federal, State, and
local rules and regulations.
Phase I scope of work includes but is not limited to:
Surveying, geotechnical investigation, and site assessment
Hydrologic and hydraulic analysis
Engineering design of drainage improvements
Plans preparation, specifications, and contract documents
Permitting with applicable state and local regulatory agencies
Bidding support
Phase II application deliverables for FDEM/FEMA review
Project 4: Wilder Creek Flood Risk Reduction
HMGP Project No. 4734-137-R | FDEM Contracts H1346 (HMGP) & H1419 (State Match)
The Wilder Creek project addresses flood risk reduction in a Taylor County area subject to recurring stormwater
inundation. Improvements will address deficiencies in the existing stormwater collection, conveyance, and
retention system consistent with HMGP Phase II requirements. The project is designed to provide protection
against a 50-year storm event and shall be completed in strict compliance with applicable Federal, State, and
local rules and regulations.
Phase I scope of work includes but is not limited to:
Surveying, geotechnical investigation, and site assessment
Hydrologic and hydraulic analysis
Engineering design of drainage improvements
Plans preparation, specifications, and contract documents
Permitting with applicable state and local regulatory agencies
Bidding support
Phase II application deliverables for FDEM/FEMA review
1.3 Funding Summary
Project HMGP Contract State Match Phase I Award State Match
Contract
Foley Cut Off Road (4734- H1269 H1270 $25,650.00 $8,977.50
138-R)
East Ellison Road (4734-135- H1267 H1272 $55,755.00 $18,585.00
R)
Dewey McGuire Road (4734- H1274 H1275 $73,395.00 $24,465.00
136-R)
Taylor County Board of County Commissioners | Perry, Florida Page 4 of 15

Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
Wilder Creek (4734-137-R) H1346 H1419 $108,832.50 $36,277.50
Taylor County is a fiscally constrained county per 218.67(1), F.S. The State Match contracts (H1270, H1272, H1275, and
H1419) were issued pursuant to 252.37(6), F.S., waiving the County's local match requirement for each HMGP award. The
firm selected under this RSOQ will work within the funded Phase I amounts. Should cost increases be approved following the
FEMA HMGP award, the County and FDEM will address adjustments in accordance with applicable contract provisions.
1.4 Reference Documents and Anticipated Permitting
A U.S. Army Corps of Engineers (USACE), Jacksonville District Floodplain Management Services (FPMS) study
- the "Taylor County-Perry Floodplain Management Services (FPMS) Final Report," dated March 2025 -
provides the hydrologic and hydraulic (HEC-RAS) modeling and alternatives analysis that form the technical basis
for the four projects described herein. The FPMS Final Report is attached to this solicitation as supplemental
information.
The selected firm shall anticipate coordinating and obtaining the approvals necessary to design and construct the
improvements, which may include, without limitation: a State of Florida Environmental Resource Permit (Florida
Department of Environmental Protection / Suwannee River Water Management District); a U.S. Army Corps of
Engineers Department of the Army permit under Section 404 of the Clean Water Act; Endangered Species Act
Section 7 coordination for listed species; and a cultural resources assessment addressing resources eligible for
the National Register of Historic Places, and Chapter 267, Florida Statutes, where applicable. It is recommended
that permit coordination be initiated at the earliest practicable time.
SECTION 2 - SCOPE OF SERVICES
The selected firm shall provide all Phase I professional engineering services required to prepare each project for
FEMA HMGP Phase II construction approval. All four projects shall be managed under a single contract with task-
level accounting that allows separate tracking of costs and deliverables by project number. The general scope of
services for each project includes the following tasks:
Task Description
Surveying & Topographic survey, boundary survey (as needed), geotechnical investigation and soil
Geotechnical borings to support design of drainage improvements.
Hydrologic & Watershed delineation, H&H modeling, capacity analysis of existing conveyance
Hydraulic Analysis systems, 50-year design storm event analysis per FEMA HMGP Phase II requirements.
Engineering Design Preliminary and final design of stormwater collection, conveyance, and retention
improvements including open swales, culverts, and related infrastructure.
Plans Preparation Production of construction drawings, specifications, and contract documents suitable for
permitting and competitive bidding.
Permitting Preparation and submittal of all required local, state, and federal permit applications
including FDEP/SRWMD, county development review, and other applicable regulatory
authorizations.
Bidding Support Preparation of bid documents; response to bidder RFIs; attendance at pre-bid
conference; bid evaluation and recommendation of award.
Phase II Application Compilation and submittal of all deliverables required for FEMA HMGP Phase II
Support construction approval through FDEM.
Project Coordination with Taylor County, FDEM Project Manager Jamie Kingsley, and applicable
Management & regulatory agencies throughout Phase I; monthly progress reports.
Coordination
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Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
The firm shall provide monthly progress reports for each project separately. All deliverables must satisfy FDEM project
manager requirements and be submitted consistent with the applicable FDEM contract period. Work shall be performed in
accordance with FEMA HMGP requirements, 2 CFR Part 200, applicable Florida statutes, and local regulations.
SECTION 3 - SUBMITTAL REQUIREMENTS
3.1 Submission Instructions
Firms must submit 1 original and 4 copies of their SOQ in a sealed package labeled:
"HMGP STORMWATER ENGINEERING DESIGN SERVICES - FOLEY CUT OFF ROAD, EAST
ELLISON ROAD, DEWEY McGUIRE ROAD & WILDER CREEK - DO NOT OPEN"
Submit to: Taylor County Clerk of Courts, 108 N Jefferson Street, Perry, Florida 32347.
The County reserves the right to reject any and all submittals, to waive informalities, and to accept the submittal deemed most
advantageous to the public interest.
3.2 Required SOQ Contents
1. Cover letter (one page maximum) signed by an authorized representative
2. Table of contents
3. Firm overview: organizational structure, office location(s), size, relevant certifications
4. Project experience: minimum 3 comparable drainage/stormwater Phase I projects
5. Key personnel: resumes for Project Manager and Lead Engineer; Florida PE license number(s)
6. Project approach: narrative describing proposed methodology, understanding of HMGP Phase I
deliverable requirements, and schedule
7. References: minimum 3 references for comparable projects completed within the past 5 years
8. Current workload statement and confirmation of capacity/availability
9. Attachment A - Respondent Acknowledgment Form (completed and signed)
10. Attachment B - Submittal Checklist (completed and signed)
11. Attachment C - Public Entity Crimes Affidavit (completed and signed)
12. Attachment D - Hold Harmless Agreement (completed and signed)
13. Proof of professional liability insurance (certificate of insurance or letter of insurability)
14. E-Verify compliance certification per 448.095, F.S.
3.3 Eligibility & Compliance Requirements
Florida-licensed professional engineering firm (Chapter 471, F.S.)
Not listed on the Florida Convicted Vendor List ( 287.133, F.S.) or Discriminatory Vendor List (
287.134, F.S.)
E-Verify enrollment and compliance per 448.095, F.S.
Not debarred or suspended from federal procurement or assistance programs
Compliance with FEMA-required conflict of interest provisions at 2 CFR 200.318
SECTION 4 - EVALUATION CRITERIA
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Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
Selection will be made on the basis of qualifications only, consistent with the Consultants' Competitive Negotiation
Act (CCNA), 287.055, F.S. Price will not be a factor in the evaluation and ranking of firms. Fees will be
negotiated with the top-ranked firm after selection.
# Criterion Points Description
1 Firm Qualifications & 30 Firm's relevant experience with HMGP Phase I engineering,
Experience stormwater/drainage design, and federally funded infrastructure
projects in Florida rural counties.
2 Key Personnel 25 Qualifications, licensure (Florida PE), and relevant experience of the
Qualifications Project Manager and Lead Engineer assigned to this contract.
3 Project Approach & 25 Demonstrated understanding of the project scope, proposed
Technical methodology, and familiarity with FEMA HMGP Phase I/Phase II
Understanding requirements and FDEM processes.
4 Past Performance & 10 Verified performance on similar projects; ability to meet schedules
References and deliverable requirements for grant-funded work.
5 Capacity & Availability 10 Adequate staffing, resources, and schedule availability to complete
Phase I deliverables within the contract period.
TOTAL 100
An Evaluation Committee appointed by the Board of County Commissioners will score and rank all responsive submittals. The
County Administrator will recommend the top-ranked firm to the Board of County Commissioners for contract authorization. If
fee negotiations with the top-ranked firm are unsuccessful, the County will negotiate with the second-ranked firm.
SECTION 5 - TERMS, CONDITIONS & LEGAL NOTICES
5.1 Procurement Authority
This procurement is conducted pursuant to 287.055, F.S. (CCNA), Chapter 125, F.S., and applicable FEMA
grant procurement requirements under 2 CFR Part 200 Uniform Guidance.
5.2 Federal Requirements
As this project is federally funded through FEMA HMGP, the following federal requirements apply and will be
included in the contract:
Equal Opportunity and Merit-Based Selection (Executive Order 14173 - no demographic preference,
quota, or workforce-balancing)
Copeland Anti-Kickback Act compliance
Contract Work Hours and Safety Standards Act
Rights to Inventions Made Under a Contract or Agreement
Debarment and Suspension (2 CFR Part 180 and Part 3000)
Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)
Procurement of Recovered Materials (2 CFR 200.322)
Appendix II to 2 CFR Part 200
FEMA General Conditions and Standard Terms applicable to HMGP sub-awards
Prohibition on Covered Telecommunications Equipment or Services (2 CFR 200.216; FY2019 NDAA
889; FEMA Policy 405-143-1)
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Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
Clean Air Act (42 U.S.C. 7401-7671q) and Federal Water Pollution Control Act (33 U.S.C. 1251-
1387)
Procurement of Recovered Materials (2 CFR 200.323)
Access to Records and Inspection Rights - contractor must provide FEMA, DHS OIG, the U.S.
Comptroller General, FDEM, and Taylor County access to all records, documents, and other materials
related to contract performance for audit and inspection purposes; this requirement flows down to all
subcontractors (2 CFR 200.337)
DHS Seal, Logo, and Flags - contractor shall not use the DHS or FEMA seal, logo, crest, or
reproductions of flags or likenesses of DHS officials without specific prior written approval from FEMA
Small, Minority, Women's, Veteran-Owned, and Labor Surplus Area Business Outreach (2 CFR
200.321) - Taylor County will take affirmative steps to solicit qualified small businesses, minority-owned
firms, women's business enterprises, veteran-owned businesses, and labor surplus area firms; the
selected firm is expected to apply the same affirmative steps to any subconsultant or subcontractor
engagements
Build America, Buy America Act (BABAA) - NOTE: HMGP is expressly exempt from BABAA
requirements per FEMA guidance; no BABAA contract clause is required for this procurement. However,
the selected firm should be aware that any Phase II construction contracts funded under this HMGP
award will be subject to domestic preference requirements applicable at that time and should incorporate
domestic material preferences into Phase I design planning accordingly
5.3 Public Records
All submittals become public records of Taylor County subject to Chapter 119, F.S. upon opening. The public
records custodian for Taylor County is the County Administrator, 201 East Green Street, Perry, Florida 32347,
(850) 838-3506.
Pursuant to 119.0701, F.S., the contractor resulting from this solicitation shall: (1) keep and maintain all public
records required by Taylor County to perform the services; (2) upon request from the County's public records
custodian, provide the County with a copy of requested records or allow the records to be inspected or copied
within a reasonable time at a cost that does not exceed the cost provided by Chapter 119, F.S.; (3) ensure that
public records that are exempt or confidential and exempt from public records disclosure requirements are not
disclosed except as authorized by law for the duration of the contract term and following completion of the
contract if the contractor does not transfer the records to the County; and (4) upon completion of the contract,
transfer, at no cost, to the County all public records in its possession or keep and maintain public records required
by the County. Failure to comply with public records disclosure requirements may result in civil or criminal
penalties. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, F.S.,
TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT,
CONTACT THE CUSTODIAN OF PUBLIC RECORDS AT: Taylor County Administrator, 201 East Green Street,
Perry, Florida 32347, (850) 838-3506.
5.4 Cone of Silence / Communications
From the date of issuance of this RSOQ until the Board of County Commissioners awards a contract, firms and
their agents shall not communicate with County staff, Board members, or Evaluation Committee members
regarding this solicitation except as expressly authorized by this document. Questions shall be submitted in
writing to the County Administrator's office.
5.5 Disqualification
Submittals that are late, incomplete, unsigned, or that otherwise fail to conform to the requirements of this RSOQ
may be rejected as non-responsive. The County reserves the right to waive minor irregularities.
5.6 Costs of Preparation
The County is not responsible for any costs incurred by firms in the preparation or submission of SOQs.
5.7 Contract
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Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
The successful firm will be required to execute a professional services contract with Taylor County, subject to
BOCC approval. The contract will incorporate all applicable FEMA HMGP and FDEM sub-award requirements,
including those contained in FDEM Contracts H1269, H1270, H1267, H1272, H1274, H1275, H1346, and H1419.
The professional services contract shall also comply with the mandatory contract provisions of 287.058, F.S.,
including: a clause permitting the County to unilaterally cancel the contract if the contractor refuses public access
to records made or received in connection with the contract; billing detail sufficient for proper preaudit and
postaudit; and compliance with state travel reimbursement rates if travel is a reimbursable expense. The contract
shall further comply with the Prompt Payment Act, 215.422, F.S., specifying payment timing and applicable
interest penalties for late payment. Records retention shall comply with 2 CFR 200.334, requiring retention for a
minimum of three years from submission of the final federal financial report, or longer if audit, litigation, or other
action is pending.
5.8 Human Trafficking Affidavit
The firm ("FE") warrants and represents that it does not use coercion for labor or services as defined in 787.06,
Florida Statutes. By submitting a response to this solicitation, the respondent certifies that it does not and will not
engage in, support, facilitate, or profit from coercion for labor or services, forced labor, or human trafficking in the
performance of any contract resulting from this solicitation. The County may terminate any contract resulting from
this solicitation if the contractor is found to have submitted a false certification or is found in violation of 787.06,
F.S., during the term of the contract.
5.9- Scrutinized Companies
As provided in 287.135, F.S., by submitting a response to this solicitation, the firm certifies that it is not on the
Scrutinized Companies that Boycott Israel List, not on the Scrutinized Companies with Activities in Sudan List,
and not on the Scrutinized Companies with Activities in the Iran Terrorism Sectors List, as those terms are
defined in 287.135, F.S. The firm further certifies that it does not have a business operation in Cuba or Syria.
Taylor County may terminate a contract with a firm if the firm is found to have submitted a false certification or if
the firm is placed on any such list during the contract term. For contracts of one million dollars or more, the firm
certifies that it is not on the Scrutinized Companies that Boycott Israel List or engaged in a boycott of Israel
pursuant to 215.4725, F.S. Submission of a response to this solicitation constitutes the firm's certification of the
foregoing.
5.10 Conflicts of Interest and Ethics
This procurement is subject to conflict of interest requirements under both federal and state law. Under 2 CFR
200.318(c), no employee, officer, or agent of Taylor County may participate in the selection, award, or
administration of a contract supported by a federal award if that individual has a real or apparent conflict of
interest. Such conflicts arise when the employee, officer, or agent; any member of his or her immediate family; his
or her partner; or an organization that employs or is about to employ any of these parties has a financial or other
interest in, or a tangible personal benefit from, a firm considered for award. Violations must be reported to FEMA.
In addition, pursuant to 112.3143, F.S., any County Commissioner or County employee who has a voting
conflict or financial interest in this procurement must disclose that conflict in the manner prescribed by Florida law
and abstain from participating in the decision. Respondent firms and their principals must disclose any known
conflicts of interest in their cover letter. The professional services contract resulting from this solicitation will
include conflict of interest provisions consistent with 2 CFR 200.318(c) and 112.313, F.S.
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Taylor County RSOQ - HMGP Stormwater Engineering Design Services 4734-138-R | 4734-135-R | 4734-136-R | 4734-137-R
ATTACHMENT A
RESPONDENT ACKNOWLEDGMENT FORM
HMGP Stormwater Engineering Design Services
Foley Cut Off Road (4734-138-R), East Ellison Road (4734-135-R), Dewey McGuire Road (4734-136-R) & Wilder Creek
(4734-137-R)
The undersigned authorized representative of the firm submitting this Statement of Qualifications acknowledges
having read and understood the full content of this RSOQ, and certifies that all information submitted is accurate
and complete.
Firm Name: _______________________________________________
Mailing Address: _______________________________________________
City, State, ZIP: _______________________________________________
Florida PE License No.: _______________________________________________
Phone: _________________________ Email: ___________________________
_______________________________________
Authorized Signature
_______________________________________
Printed Name and Title
___________________________
Date
Taylor County Board of County Commissioners | Perry, Florida Page 10 of 15