Attachment 3 - Organizational Conflict of Interest.pdf
PDF 3 MB Posted
- Solicitation number
- 36C26323Q1107
About this file
This document is an organizational conflict of interest certification statement for a federal contract solicitation from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 23. The solicitation is for otolaryngology/ENT physician services to be provided at the Central Iowa Health Care System - Des Moines Veterans Administration from November 1, 2023 through October 31, 2028. Offerors must disclose any present, planned, or potential organizational conflicts of interest relating to the required services. If conflicts exist, offerors must provide a concise statement describing relevant facts. Offerors may also provide statements and explanations demonstrating how their organizational systems or actions would avoid or mitigate potential conflicts. The certification must be signed and dated by an authorized official of the offeror.
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Text version
SOLICITATION #:
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
] ____________________________________ represents that no individuals involved with the solicitation ________________________________ 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 Central Iowa Health Care System – Des Moines 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 Central Iowa Health Care System – Des Moines 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
Organizational Conflicts of Interest Contractor Certification
CONTRACTOR NAME:
ADDRESS:
ATTACHMENT 3
A-3
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| Contractor Company: |
| Solicitation#: |
| Address: |
| No COI affirmation: Choice1 |
| Date7_af_date: |
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