36C26119Q0007-003.docx

Attachment 3 – Organizational Conflict of Interest

CONTRACTOR NAME

CONTRACTOR NAME: ______________________________

ADDRESS: _______________________________________

SOLICITATION # 36C26118Q0466 Emergency Department 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 36C26118Q0466 Emergency Department Physician 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 Veterans Affairs Southern Nevada Healthcare System (VASNHS) 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 Veterans Affairs Southern Nevada Healthcare System (VASNHS) 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

Attachment 3 – Organizational Conflict of Interest 36C26119Q0007