Laserfiche WebLink
Y..“4 T�J1(F <br /> .ti �_ DISPUTE DISCLOSURE <br /> VI, `_ ,I City of Sunny Isles Beach <br /> A 18070 Collins Avenue <br /> •':i,o•,00.' Sunny Isles Beach,FL 33160 <br /> 'r”,o. ,en' Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> Answer the following questions by pladng a "X" after "Yes" or "No". If you answer "Yes", please <br /> explain in the space provided, or on a separate sheet attached to this form. <br /> 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the <br /> Department of Professional Regulations or any other regulatory agency or professional associations within the last <br /> I <br /> five (5) years? '/ <br /> YES NO <br /> 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a <br /> contract or job related to the services your firm provides in the regular course of business'within the last five (5) <br /> years? / <br /> YES NO V <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> or litigation in the past five (5) years that is related to the services your firm provides in the regular course of <br /> business? <br /> YES NO ✓ If yes, state the nature of the request for equitable adjustment, contract <br /> daim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the <br /> monetary amounts of extended contract time involved. <br /> I hereby certify that all statements made are true and agree and understand that any misstatement or <br /> misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid <br /> for the City of Sunny Isles Beach. <br /> X Ck4N COttp Augusr ocf c20 AS- <br /> / <br /> Firm / Date <br /> (lOM'P1Z —C4/VC tit;Z 12Pctato/�Sj, (ts <br /> Authorized Signature • Print or Type Name and Title <br /> DECEMBER 28.2010 6 of 10 <br />