12-Vendors Conflict of Interest Form.pdf
PDF 155 KB Posted
- Attached to
- RFQ No. 2026-013 Owner's Representative Services for Mid-Town Construction Projects State and local contract opportunity
- Solicitation number
- 2026-013
- Issued by
- Palm Beach County, Florida
About this file
This is a Conflict of Interest Statement form issued by the Town of Palm Beach Procurement and Contracts Management Division for RFQ No. 2026-013, which solicits proposals from qualified firms to provide Owner's Representative Services for Mid-Town Construction Projects in Palm Beach, Florida. The Town is seeking professional advice and engineering services to oversee the progressive design-build contractor and construction of the Mid-town Seawall Replacement project, with potential engagement for additional projects including the Mid-Town Linear Park construction, Mid-Town Bathroom Renovation, and Mid-Town Paving and Infrastructure Improvements. Services for the Seawall project encompass reviewing pricing to establish guaranteed maximum cost, site inspection and testing, communications and public relations, survey/geotechnical/utility assessment, and initial program inception. A non-mandatory pre-proposal meeting will be conducted virtually via Teams, with attendance strongly encouraged as the only forum for direct clarification from Town staff. Proposals cannot be withdrawn for one hundred eighty days from the opening date, and award will be made to the proposer offering best value to the Town. The selected firm will be ineligible to be awarded the Mid-Town Seawall Replacement Progressive Design-Build Project RFQ No. 2026-012.
The Conflict of Interest Statement requires vendors to disclose any potential conflicts of interest and certify their status regarding relationships with Town employees, elected officials, appointed officials, and ownership interests. Vendors must check applicable boxes indicating either no conflict of interest or submission of information regarding potential conflicts. The disclosure obligation is continuing in nature, requiring immediate notification of any conflicts that arise during contract performance and any renewal or extension periods. The statement is subject to Town of Palm Beach policies, the Palm Beach County Code of Ethics, and Florida Statutes Chapter 112, Part III.
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Text version
Town of Palm Beach
Procurement and Contracts Management Division
CONFLICT OF INTEREST STATEMENT
Solicitation No. _________________ Proposal from __________________
This solicitation/proposal (whichever is applicable) is subject to the conflict-of-interest provisions of the policies and Code of Ordinances of the Town of Palm Beach, the Palm Beach County Code of Ethics, and the Florida Statutes. During the term of this award and any renewals or extensions thereof, the VENDOR shall disclose to the Town of Palm Beach any possible conflicts of interest(s). The VENDOR’S duty to disclose is of a continuing nature and any conflict of interest shall be immediately brought to the attention of the Town of Palm Beach. The terms below shall be defined in accordance with the policies and Code of Ordinances of the Town of Palm Beach, the Palm Beach County Code of Ethics, and Ch. 112, Part III, Florida Statues.
CHECK ALL THAT APPLY
NO CONFLICT:
____ To the best of our knowledge, the undersigned business has no potential conflict of interest for this solicitation/proposal due to any other clients, contracts, or property interests.
____ To the best of our knowledge, the undersigned business has no employment or other contractual relationship with any Town of Palm Beach employee, elected official or appointed official.
____ To the best of our knowledge, the undersigned business has no officer, director, partner or proprietor that is a Town of Palm Beach purchasing agent, other employee, elected official or appointed official. The term “purchasing agent”, “elected official”, or “appointed official”, as used in this paragraph, shall include the respective individual’s spouse or child, as defined in Ch. 112, Part III of the Florida Statues.
___ To the best of our knowledge, no Town of Palm Beach employee, elected official or appointed official has a material or ownership interest of (5% or greater ownership) in our business.
POTENTIAL CONFLICT
___ The undersigned business, by attachment to this form, submits information which may be a potential conflict of interest due to any of the above listed reasons or otherwise.
Company __________________________________________________________
Authorized Signature _________________________________________________
Name (print or type) __________________________________________________
Title ______________________________________________________________
Date _______________________
| Proposal from Awarded PSA: |
| Name print or type: |
| Title: |
| Date: |
| Solicitation No: |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
| Check Box5: Off |
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| Check Box7: Off |
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