Attachment 2 - Contractor Organizational Conflict of Interest.pdf
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- Attached to
- Q201--MSO-2020-CMP-0029 Capitated CBOC - Cookeville and Roane Cnty - Long-Term Base + 6 options
- Solicitation number
- 36C24920R0060
About this file
This document contains an organizational conflict of interest certification statement template for a federal contractor providing services, as well as details of a solicitation by the Department of Veterans Affairs for capitated community-based outpatient clinic services. The solicitation seeks proposals to operate a CBOC providing primary care services to veterans residing in Cookeville, Tennessee and Roane County, Tennessee. Interested offerors must be registered in the VetBiz and SAM databases. The NAICS code is 621498 with a size standard of $22 million. Proposals must conform to the requirements of the forthcoming RFP, which will be posted on SAM. The selection process will follow FAR Parts 12 and 15. Questions may be directed to the point of contact. The anticipated release date for the solicitation is June 4, 2020.
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Attachment 2 – Contractor Organizational Conflict of Interest
APPENDIX A
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION #
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 [____Solicitation # and Service Type___] 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 ___[NAME OF VAMC] _________ 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___NAME OF VAMC _________ 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
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