Laserfiche WebLink
<br /> <br />DISPUTE DISCLOSURE <br /> <br />City of Sunny Isles Beach <br />18070 CoDinB Avenue <br />Sunny Islea Beach, FL 33160 <br />Telephone: (305) 947-0606 Fax: (305) 949-3113 <br /> <br />DISPUTE DISCLOSURE FORM <br /> <br />Answer the following questions by placing a "X" after -VeS' or "No". If you answer "'YeS', please <br />explain in the space provided, or on a separate sheet attached tit this form. <br /> <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 assodations within the last <br />five (5) years? <br /> <br />YES <br /> <br />NO r- <br /> <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 /> <br />YES <br /> <br />NO r=: <br /> <br />19.3. Has your firm had against It or filed any requests for equitable adjustment, contract daims, 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 /> <br />YES NO ~ If yes, state the nature of the request for equitable adjustment, contract <br />claim, litigation, or protest, and state a brief desaiption of the case, the outcome or status of the suit and the <br />monetary amounts of extended contract time involved. <br /> <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 /> <br />UOl~ <br />:00z gna - /- - . <br /> <br />5/:2cj /20I{ <br />Date <br />j?AwY ~fn+ - OWN ~ <br />Print or Type Name and Title <br /> <br />6017 <br /> <br />DECEMIl8t28. 2010 <br /> <br />., <br />J <br />