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0 <br /> ® e 'f. <br /> s � DISPUTE DISCLOSURE <br /> Ir; a <br /> ® •. j sayCity of Sunny Isles Beach <br /> ® • f 18070 Cairn Artie�• o ' • Sunny Isles Beach.FL 33160 <br /> ea„a <br /> Telephone:(306)947-0I9:6 Fax:005)949-3113 <br /> ® DISPUTE DISCLOSURE FORM <br /> Answer 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 /> ® 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 /> ® <br /> 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a <br /> ® <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 <br /> ® 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> ® Cr 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 /> 0 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 /> k Ran,nye 14,4"• 4,,,1/41 ,(-LA- �1(�Z bz <br /> Firm Date U <br /> 2:15 rti 'f/- 'NG nitnei <br /> 0 Auth Signature Print or Type Name and Title <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> orceaa n,2010 6 of 7 <br /> ® Curtis + Rogers Design Studio RFQ 12-04-02 59 <br />