Laserfiche WebLink
40 . <br /> - <br /> v( 12 <br /> DISPUTE DISCLOSURE <br /> .\ City of Sunny Isles Beach <br /> `ov' 16010 CdOon Avenue <br /> . ` Sunny Isles Beach,FL 33160 <br /> o.....''' Telephone:(305)947-0606 Fax(305)649-3113 <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 /> 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 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 /> 411 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 /> I hereby certify that all statements made are true arid 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 Corp.D/B/A Bettoli Vending (4/11/ 1} <br /> Firm Date <br /> Maurizio L Bettoli,Director of Operations <br /> Authorized Signature Print or Type Name and Title <br /> 6 of 7 <br /> 411 I <br /> ti <br />