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IArchitectures 6-10 <br /> IuHN.,, <br /> F, <br /> _/Scr��� DISPUTE DISCLOSURE <br /> x <br /> _ -v)- : City of Sunny Isles Beach <br /> �••\ ._,:.`;- . • 18070 Collins Avenue <br /> 'to•0 Sunny Isles Beach,FL 33160 <br /> i et'v 0. .0 .3'o• <br /> Telephone:(305)947-0606 Far(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> IAnswer the following questions by placing 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 /> I19.1. 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 x <br /> I 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 /> 1 YES x NO <br /> I 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 /> I YES x NO 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 /> 1 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 /> Ifor the City•of Sunny Isles Beach. <br /> Atki North America, Inc. April 17, 2012 <br /> Firm Date <br /> I ...art . . David Carter, CCM, Senior Vice President <br /> Auth r Sig-ture W Print or Type Name and Title <br /> I <br /> 1 Please see attached for further information/details. <br /> I <br /> I <br /> DECEMBER 28.2010 6 of 7 <br /> 1 0006.027944.0512 Atkins I City of Sunny Isles Beach, RFQ No. 12-04-02 <br /> A <br />