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) CONFLICT OF INTEREST City of Sunny Isles Beach 18070 Collins Avenue Sunny Isles Beach, FL 33160 Telephone: (305) 947-0606 Fax: (305) 949-3113 CONFLICT OF INTEREST STATEMENT The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or employee of the City of Sunny Isles Beach or its agencies. STATE OF FLORIDA COUNTY OF Broward BEFORE ME, the undersigned authority, personally appeared Peter Moore, P.E., LEED AP deposes, and states: . who was duly sworn, of and principal office in 18.1. I am rhf'n MoorE) ,'Inn AsSOr.iiltf'S the President with a local office in Miami RFQ 18.2. The .above namedentltv Is submitting a 'tmt for the City of Sunny Isles Beach, .e.i& No. 11-11-02 described as: Civil Entln..rrnl; Servl... 10 O"l&n 51.... and orarnagefhe Affiant has madEldiligent inquiry and provides the information contained in this 111'''''''''.&1''''1'''-40 Affidavit based upon his. own knowledge. RFQ 18.3 The Affiant states that only one submittal for the above-etd is being submitted and that the above named entity has no financial interest in other entities submitting -BTds for the same project. RFQs 18.4 Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity's submittal for the above RFQ This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project. 18.5 Neither the entity nor its affiliates, nor anyone associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. 18.6 Neither the entity, nor its affiliates, nor anyone associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project. 18.7 I certify that no member of the entity's ownership or management is presently applying for any employee position or actively seeking an elected position with the City of Sunny Isles Beach. 18.81 certify that no member of the entity's ownership or management, or staff has a vested interest in any aspect of the City of Sunny Isles Beach. Dated this Oiet of interest is identified in the provision of services, I, on behalf of the above named entity, will of Sunny Isles B December , 2011 Peter Moore. P.L LEEDAP. President Print or Type Name and Title AFFIANT Sworn to and ubscribed before me this ~ day of December , 2011 10 Pers nally Known x OR LJ Prod cad Identification ; Type of )~enliflcation. <tLr ~ NOTARY PUBLIC STATE OF FLORIDA N6TARYPUBI.tC.srATEO~FLOlUDA ""'''''''';. Leigh Barron {W \ Coinmisslon # EEO?8032 \'flilliExpires:JUNE 06,2015 n~EDTmU ^Ti~~'TIC !lONDING ca, me. DECEMBER 28. 2010 CHeRE M$SOC1AI~S 50f7 IIrIJ No./I-1I-1I1 Cillil f.'lIljilleerillg Senire.\ to f)eSi!lIl.l'lft'ellll/tI /Jroilll/ljl' IllIflrtll'fl1ll'l1ls 7.9