Attachment 2 - Contractor Organizational Conflict of Interest.pdf
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- Solicitation number
- 36C24920R0007
About this file
This document contains an organizational conflict of interest certification statement template and details of a federal contract solicitation for Community Based Outpatient Clinic services. The certification statement template requires the contractor to disclose any past, present or planned interests or conflicts relating to the services solicited. Contractors must also provide similar statements for any consultants or subcontractors.
The solicitation seeks proposals to operate Community Based Outpatient Clinics in Dover, TN and Hopkinsville, KY to provide primary care services to Veterans on behalf of the Tennessee Valley Healthcare System. The anticipated NAICS code is 621498 with a size standard of $22 million. The solicitation is expected to be released on or around June 11, 2020 and will result in indefinite delivery, indefinite quantity contracts awarded to responsive and responsible offerors deemed most advantageous to the Government. The source selection process will follow FAR Parts 12 and 15. Questions must be submitted in writing to the point of contact by the specified deadline.
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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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