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<br />l <br /> <br />) <br /> <br /> <br />DISPUTE DISCLOSURE <br /> <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles 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 "Yes" or "No". If you answer "Yes", please <br />explain in the space provided, or on a separate sheet attached to 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 associations within the last <br />five (5) years? <br /> <br />YES <br /> <br />NO x <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 x <br /> <br />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 /> <br />\ <br />I <br /> <br />YES NO x 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 /> <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 /> <br />December 1, 2011 <br />Date <br /> <br />Peter Moore, P.E., LEED AP, President <br />Print or Type Name and Title <br /> <br />DEcEMseR 29. 2010 <br /> <br />CHeRE <br />MSSU(IAI~S <br /> <br />60f7 <br /> <br />Ilro No. 11.11-111 Civil !:lIljillrerin!} ServiU's to /Jesiljll SireI'I lIlII! IJfllil1l1!}I' {IJlIJfllmlleJJls <br /> <br />7.10 <br />