36C25719Q0499-00002000.docx

5. PROJECT NUMBER (if applicable)

CODE

7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) none 00002 04-25-2019 36C257 Department of Veterans Affairs VHA Procurement Office West 11495 Turner Road El Paso, Texas 79936

36C257 El Paso Contracting

To all Offerors/Bidders

36C25719Q0499 04-09-2019

X X X

X Reason for Amendment:

a. Provide questions and answers as attached.

b. All other terms and conditions remain in full force and effect.

Marisela Galarza Contracting Officer Questions/ Answers:

1. Will the provider be responsible for intern or residence training?

Answer: No

2. Is this facility affiliated with a teaching facility/ university?

Answer: Yes Note: If required attachments per solicitation (D.1, D.2, D.3, D.4, and D.5) cannot be accessed through FBO, upon receipt of offers from vendors, attachments will be sent to the vendor Point of Contact.

S02 QUALITY ASSURANCE SURVEILLANCE PLAN - BELOW

PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined. Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. 100% surveillance: Random inspection of qualification documents

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

6.SAMPLE QASP PERFORMANCE REPORT DATE: __________________

Tailor to specific procurement. Consider the performance measures the VA may have for the service the procurement involves.

Reference Performance Requirement

Method Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

Periodic Sampling

Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Directive 6500.6.

Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However, a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also, there should have been NO significant weaknesses identified.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also, there should have been NO significant weaknesses identified.

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/pdfs/CPARS-Guidance.pdf p. A2-1):

8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Report (CR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CR in writing. The CR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CR will also state how long after receipt the contractor has to present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

5. DATES

a. CR PREPARED

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

852.209-70.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 to provide response.

852.209-70.ORGANIZATIONAL CONFLICTS OF INTEREST (JAN 2008)

(a) It is in the best interest of the Government to avoid situations which might create an organizational conflict of interest or where the offeror’s performance of work under the contract may provide the contractor with an unfair competitive advantage. The term “organizational conflict of interest” means that because of other activities or relationships with other persons, a person is unable to render impartial assistance or advice to the Government, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or the person has an unfair competitive advantage.

(b) The offeror shall provide a statement with its offer which describes, 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.

(c) Based on this information and any other information solicited or obtained by the contracting officer, the contracting officer may determine that an organizational conflict of interest exists which would warrant disqualifying the contractor for award of the contract unless the organizational conflict of interest can be mitigated to the contracting officer's satisfaction by negotiating terms and conditions of the contract to that effect. If the conflict of interest cannot be mitigated and if the contracting officer finds that it is in the best interest of the United States to award the contract, the contracting officer shall request a waiver in accordance with FAR 9.503 and 48 CFR 809.503.

(d) Nondisclosure or misrepresentation of actual or potential organizational conflicts of interest at the time of the offer, or arising as a result of a modification to the contract, may result in the termination of the contract at no expense to the Government. Page 2 of 2

APPENDIX A

[CONTRACTOR NAME:_______________________________________________]

[ADDRESS]

SOLICITATION NUMBER: 36C25719Q0499

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 [36C25719Q0499 – Cardiologist Services] in 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 Amarillo VA Health Care System 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 Amarillo VA Health Care System 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

End of Document image2.emf

FSC VENDOR FILE REQUEST FORM

NEW

VA FACILITY INFORMATION

STATION NUMBER

STATION CONTACT

STATION PHONE NUMBER STATION FAX NUMBER

STATION EMAIL ADDRESS

PAYEE/VENDOR TYPE (Select one)

C - COMMERCIAL

E - EMPLOYEE

I - INDIVIDUAL/HONORARIUM

V - VETERAN

F - FEDERAL AGENCY

O - FOREIGN

A - AGENT CASHIER

U - UTILITY

FACTS ID

MISCELLANEOUS ACTIONS (Select one) WINRS ASSIGNMENT (All applicable documents)

BILL OF COLLECTIONS SETTLEMENT/TORTS

ALAC/LGY ACCOUNT #

UPDATE

DATE

PAYEE/VENDOR INFORMATION

COMMERCIAL VENDOR REGISTERED IN SAM.GOV

(Required IAW FAR 4.1102)

DUNS NUMBER

DUNS+4

SSN/TIN

NPI

SMALL BUSINESS - VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN

SAM OR FURNISH SBA CONFIRMATION

VENDOR NAME

DBA

CONTACT

EMAIL ADDRESS

PHONE NUMBER

CURRENT ADDRESSS (Include Street, City, State and Zip Code)

PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)

EFT/ACH (Required IAW 31 CFR Part 208)

BANK NAME

BANK ADDRESSS (Include City, State and Zip Code)

NINE-DIGIT BANK ROUTING NUMBER

ACCOUNT NUMBER

ACCOUNT TYPE

CHECKING SAVINGS

PAYEE/VENDOR PRINTED NAME & TITLE

SIGNATURE

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES

FOR QUESTIONS REGARDING THIS FORM:

NVF CONTACT INFORMATION:

NATIONWIDE VENDOR FILE CUSTOMER SERVICE:

EMAIL: VAFSCVENDOT@VA.GOV

FOR ALL OTHER INQUIRIES:

CUSTOMER CARE CENTER: 1-877-353-9791

STATION CARE CENTER: 1-866-372-1141

SUBMIT ALL DOCUMENTATION VIA:

SECURE FAX: 512-460-5221

VA FORM

OCT 2014 10091

mailto:VAFSCVENDOT@VA.GOV

Instructions for FMS Vendor File Request Form

1. NEW box option - Check box if you are a new vendor not in the FMS system.

2. UPDATE box option - Check box if you are an existing vendor in the FMS system.

VA Facility Information

3. Station # - This portion pertains to the VA Station submitting this form, provide your station 3 digit station number. FOR

STATION USE ONLY

4. Station Contact Name - VA Station employee. FOR STATION USE ONLY

5. Station Phone - VA Station employee direct number. FOR STATION USE ONLY

6. Station Fax Number - VA Station fax number. FOR STATION USE ONLY

7. Station Email - VA Station employee work email address. FOR STATION USE ONLY

Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED

Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required. OPTIONAL

· ALAC Vendors - include the 6 digit account number OPTIONAL, USE ONLY IF ALAC

· Assignment of Claims- include Notice of Assignment & Instrument of Assignment OPTIONAL, ONLY IF ASSIGNMENT

· Federal Vendors- include the 2 digit Facts ID OPTIONAL, USE ONLY IF FEDERAL AGENCY

· Foreign Vendors- include W8Ben & IRS notice 565(ITIN) or IRS notice 575 (EIN) OPTIONAL, ONLY FOR FOREIGN

COUNTRY

Payee/Vendor Information

8. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this box. OPTIONAL

9. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B)

OPTIONAL

10. DUNS+4 - If you have more than one EFT account number for the same DUNS number and same physical location as defined by the

DUNS address complete this section. OPTIONAL

11. SSN/TIN - The Social Security Number (SSN) is the nine-digit number. The Tax Identification Number (TIN) is the nine-digit number which is either an Employer Identification Number (EIN); complete this section with SSN, TIN, EIN or ITIN. REQUIRED

12. NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL

13. Small Business - Check box if applicable OPTIONAL

14. Vendor Name - Provide legal name as it is on file with the IRS REQUIRED

15. DBA - Doing Business As name complete if applicable OPTIONAL

16. Contact - Name of Point of Contact if additional information is required OPTIONAL

17. Email - Point of Contact email address OPTIONAL

18. Phone - Point of Contact phone number OPTIONAL

19. Current Address - Provide your most current address, city, state & zip code REQUIRED

20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES

21. EFT/ACH (REQUIRED IAW 31CFR Part 208)

22. US. Bank Name - provide financial institution name city, state & zip code.

23. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number)

24. US. Account # - Provide bank account number maximum 17 digits

25. Account Type - Check appropriate box that is associated with account number provide above

26. Payee/Vendor Printed Name & Title - Name and title of person completing payee/vendor information. REQUIRED

27. Payee/Vendor Signature - Signature of person completing payee/vendor information. REQUIRED

Please fax the completed form to 512-460-5221 for processing.

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg

Department of Veterans Affairs logo

FSC VENDOR FILE REQUEST FORM

F S C VENDOR FILE REQUEST FORM

VA FACILITY INFORMATION

STATION NUMBER

STATION CONTACT

STATION PHONE NUMBER

STATION FAX NUMBER

STATION EMAIL ADDRESS

PAYEE/VENDOR TYPE (Select one)

FACTS ID

MISCELLANEOUS ACTIONS (Select one)

DATE

PAYEE/VENDOR INFORMATION

DUNS NUMBER

DUNS+4

SSN/TIN

NPI

VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN

SAM OR FURNISH SBA CONFIRMATION

VENDOR NAME

DBA

CONTACT

EMAIL ADDRESS

PHONE NUMBER

CURRENT ADDRESSS (Include Street, City, State and Zip Code)

PREVIOUS ADDRESSS (Include Street, City, State and Zip Code)

EFT/ACH (Required IAW 31 CFR Part 208)

BANK NAME

BANK ADDRESSS (Include City, State and Zip Code)

NINE-DIGIT BANK ROUTING NUMBER

ACCOUNT NUMBER

ACCOUNT TYPE

PAYEE/VENDOR PRINTED NAME & TITLE

SIGNATURE

NORMAL PROCESSING TIME IS 3 - 5 BUSINESS DAYS. WE DO NOT ACCEPT INVOICES

FOR QUESTIONS REGARDING THIS FORM:

NVF CONTACT INFORMATION:

NATIONWIDE VENDOR FILE CUSTOMER SERVICE:

EMAIL: VAFSCVENDOT@VA.GOV

FOR ALL OTHER INQUIRIES:

CUSTOMER CARE CENTER: 1-877-353-9791

STATION CARE CENTER: 1-866-372-1141

SUBMIT ALL DOCUMENTATION VIA:

SECURE FAX: 512-460-5221

VA FORM

OCT 2014

V A FORM 1 0 0 9 1, OCTOBER 2014

10091

Instructions for FMS Vendor File Request Form

1. NEW box option - Check box if you are a new vendor not in the FMS system.

2. UPDATE box option - Check box if you are an existing vendor in the FMS system.

VA Facility Information

3. Station # - This portion pertains to the VA Station submitting this form, provide your station 3 digit station number. FOR STATION USE ONLY

4. Station Contact Name - VA Station employee. FOR STATION USE ONLY

5. Station Phone - VA Station employee direct number. FOR STATION USE ONLY

6. Station Fax Number - VA Station fax number. FOR STATION USE ONLY

7. Station Email - VA Station employee work email address. FOR STATION USE ONLY

Payee/Vendor Type - Check the appropriate Payee/Vendor Type box. REQUIRED

Miscellaneous Actions - Check the appropriate Payee/Vendor Type box, some additional documentation required. OPTIONAL

· ALAC Vendors - include the 6 digit account number OPTIONAL, USE ONLY IF ALAC

· Assignment of Claims- include Notice of Assignment & Instrument of Assignment OPTIONAL, ONLY IF ASSIGNMENT

· Federal Vendors- include the 2 digit Facts ID OPTIONAL, USE ONLY IF FEDERAL AGENCY

· Foreign Vendors- include W8Ben & IRS notice 565(ITIN) or IRS notice 575 (EIN) OPTIONAL, ONLY FOR FOREIGN COUNTRY

Payee/Vendor Information

8. Commercial Vendor Registered in SAM.gov - If you are registered in System of Awards Management & have a DUNS number check this box. OPTIONAL

9. DUNS # - Data Universal Numbering System (DUNS) is a unique 9-digit number that is administered by Dun and Bradstreet (D&B) OPTIONAL

10. DUNS+4 - If you have more than one EFT account number for the same DUNS number and same physical location as defined by the DUNS address complete this section. OPTIONAL

11. SSN/TIN - The Social Security Number (SSN) is the nine-digit number. The Tax Identification Number (TIN) is the nine-digit number which is either an Employer Identification Number (EIN); complete this section with SSN, TIN, EIN or ITIN. REQUIRED

12. NPI - A standard 10 digit unique identifiers for health care providers, complete this section if applicable. OPTIONAL

13. Small Business - Check box if applicable OPTIONAL

14. Vendor Name - Provide legal name as it is on file with the IRS REQUIRED

15. DBA - Doing Business As name complete if applicable OPTIONAL

16. Contact - Name of Point of Contact if additional information is required OPTIONAL

17. Email - Point of Contact email address OPTIONAL

18. Phone - Point of Contact phone number OPTIONAL

19. Current Address - Provide your most current address, city, state & zip code REQUIRED

20. Previous Address - Provide previous address, city, state and zip code REQUIRED FOR ADDRESS CHANGES

21. EFT/ACH (REQUIRED IAW 31CFR Part 208)

22. US. Bank Name - provide financial institution name city, state & zip code.

23. US. Nine-Digit Bank Routing Number - Provide 9 digit routing number from check ( DO NOT use Deposit slip routing number)

24. US. Account # - Provide bank account number maximum 17 digits

25. Account Type - Check appropriate box that is associated with account number provide above

26. Payee/Vendor Printed Name & Title - Name and title of person completing payee/vendor information. REQUIRED

27. Payee/Vendor Signature - Signature of person completing payee/vendor information. REQUIRED

Please fax the completed form to 512-460-5221 for processing.

Tammy Bailey

Missie Vaccaro

VA Form 10091, FSC VENDOR FILE REQUEST FORM

OCTOBER 2014

AUGUST 2013

10091, FSC, VENDOR, FILE

C - COMMERCIAL

"NEW" CHECKBOX: 1

V A FACILITY INFORMATION: STATION NUMBER: 504

SIGNATURE: Hassan Wilson, Contract Specialist

SIGNATURE: hassan.wilson@va.gov

ACCOUNT NUMBER LINE 2 OF 2: 9152171241

ACCOUNT NUMBER LINE 2 OF 2: 9152171261

ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0

ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0

ACCOUNT TYPE: "SAVINGS" CHECKBOX: 0

"UPDATE" CHECKBOX: 0

Date:

PAYEE/VENDOR INFORMATION: COMMERCIAL VENDOR REGISTERED IN SAM.GOV (Required IAW FAR 4.1102) CHECKBOX: 1 image1.emf

CONTRACTOR CERTIFICATION: IMMIGRATION AND NATIONALITY ACT OF 1952, AS AMENDED

The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals;

While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent Amendments, as well as applicable Federal Acquisition Regulations.

If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.

The Contractor agrees to obtain a similar certification from its subcontractors.

Signature:

Date:

Typed Name and Title:

Company Name:

This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.