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1 <br /> SJNNY ls<E <br /> IOA� , .•T JB' DISPUTE DISCLOSURE <br /> V _ h_ 1 <br /> City of Sunny Isles Beach <br /> I .' , 18070 Collins Avenue <br /> ,�➢�.,,pf`°oti`' Sunny Isles Beach,FL 33160 <br /> 'r o,,�„r" Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please <br /> 1. 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 /> I Department of Professional Regulations or any other regulatory agency or professional associations within the last <br /> five (5) years? <br /> IYES NO X <br /> 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a <br /> I 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 /> 3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> I 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 X NO 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 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.I <br /> DRC Emergency Services, LLC 5/,, <br /> 01 /►.?) <br /> Firm Date <br /> ���'�� <br /> Authorized Signatuf Aa <br /> h.!7n ii Kristy Fuentes VP/Secretary/Treasurer <br /> Print or Type Name and Title <br /> I <br /> I <br /> I <br /> I <br /> 6 of 10 <br /> I120 <br /> 1 <br />