Laserfiche WebLink
Dispute Disclosure Form <br />DISPUTE DISCLOSURE <br />". city of Sunny Isles Beach <br />�,� �, remocoancerenw <br />- Tr4pnbrt ib5i 9a'-0fi0E Faz::bJi 9d'sJ'r] <br />DISPUTE DISCLOSURE FORM <br />Answer the following questions b ' <br />y placing a � X' after "yes- or "NO ". If you answer "Ves ", 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 />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 o job related to the services Your firm provides in the regular course of business within the last five (5) <br />years? <br />YES No _ <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 1�61 If yes, state the nature of the request for equitable adjustment, contract <br />claim, 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 hrttrer consideration of this &d <br />fa- the City of Sunny Isles Beach. <br />LGC <br />Fnn — Date <br />�~ V4 A11'6-9- Fld -F-W -# r l-SAI W-0-Pk- <br />Authorized bigReame Print or Type Name and Title <br />o .n MID E0r7 <br />29 <br />