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I <br /> Civil/Environmental Engineering 1 6-10 <br /> I <br /> 1 •t1,HNI <br /> s e(o� ) <br /> DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> <<or•�a. Sunny Isles Beach.FL 33160 <br /> I . a. +u Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", pleas <br /> explain in the space provided, or on a separate sheet attached to this form. <br /> 1 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by th <br /> Department of Professional Regulations or any other regulatory agency or professional associations within the la! <br /> five (5) years? <br /> IYES NO x <br /> I19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from <br /> contract or job related to the services your firm provides in the regular course of business within the last five (f <br /> years? <br /> IYES x NO <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protest! <br /> or litigation in the past five (5) years that is related to the services your firm provides in the regular course c <br /> business? <br /> I YES x NO If yes, state the nature of the request for equitable adjustment, contra( <br /> claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and th <br /> monetary amounts of extended contract time involved. <br /> 1 I hereby certify that all statements made are true and agree and understand that any misstatement c <br /> misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bir <br /> I for the City,of Sunny Isles Beach. <br /> Atki North America, Inc. April 17, 2012 <br /> Firm Date <br /> 1IliDavid Carter, CCM, Senior Vice President <br /> Authors Sig.tore I Print or Type Name and Title <br /> I <br /> 1 Please see attached for further information/details. <br /> I <br /> 1 DtcE.ern 28.2010 6 of 7 <br /> I0006027944.0512 Atkins I City of Sunny Isles Beach, RFQ No. 12-04-02 <br />