36C25018Q9284-002.pdf

[CONTRACTOR NAME] ______________________________________

[ADDRESS] _______________________________________________

SOLICITATION # 36C25018Q9284

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] __________________________________ represents that the individuals who will be presented as candidates for Key Personnel and Temporary Emergency Substitutions section of the solicitation [_36C25018Q9284, Radiology Oncology Services__] have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Northern Indiana HCS Veterans Administration under the referenced solicitation.

None of the candidates submitted in response to the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual organizational conflicts of interest relating to the services to be provided to the Northern Indiana HCS Veterans Administration under the referenced solicitation.

OR

[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.

NAME OF CERTIFYING OFFICIAL

TITLE

SIGNATURE DATE