36C25019Q0835-004.pdf

ATTACHMENT D3 - ORGANIZATIONAL CONFLICTS OF INTEREST (JAN 2008)

All healthcare contracts require response to the following provision as prescribed in VAAR 809.507-1(b).

Please use the form in APPENDIX A (below) to provide response.

APPENDIX A

Contractor Name: ____________________________ Address: ____________________________

Solicitation Number 36C25019Q0835 Description On-Site Psychiatry Physician Services

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] Contractor Name: ____________________________ represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation number 36C25019Q0835 and On-Site Psychiatry Physician 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 Battle Creek VA Medical Center (BCVAMC) Veterans Administration under the referenced solicitation.

None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Battle Creek VA Medical Center (BCVAMC) 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