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• <br /> Lt(0/ DISPUTE DISCLOSURE <br /> ms,.µ:is City of Sunny Isles Beach <br /> ,�. 18070 Collins Avenue <br /> ,;0 000�` Sunny Isles Beach,FL 33160 <br /> o ,v '' Telephone:(305)947-0606 Fax(305)949-3113 <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 /> 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 /> 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 /> YES NO X <br /> 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 /> ® YES NO X 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 /> 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 /> Bettoli Trading -).D/B/A Bettoli Vending q/y/ 1/- <br /> Firm <br /> Firm Date <br /> Maurizio L Bettoli,Director of Operations <br /> Authorized Signature Print or Type Name and Title <br /> 6 of 7 <br /> 0 <br />