Attachment 3 Organizational Conflict of Interest.pdf
PDF 116 KB Posted
- Attached to
- 36C25026Q0276 Radiation Safety Officer
- Solicitation number
- 36C25026Q0276
About this file
This is a Contractor Conflict of Interest Certification Statement form for federal contracting under Solicitation 36C25026Q0276 issued by the Veterans Administration Medical Center (VAMC).
The form requires contractors to certify their organizational conflict of interest status by selecting one of two options. The first option allows contractors to represent that no individuals involved with the solicitation have any present, past, or currently planned financial, contractual, organizational, or other interests that would create actual or potential organizational conflicts of interest relating to services to be provided to the named VAMC. The second option requires contractors to attach a detailed statement describing all relevant facts concerning any past, present, or currently planned conflicts of interest and to provide the same information for any identified consultants and subcontractors that will provide services under the solicitation. Contractors may also provide evidence of how their organizational and management systems would avoid or mitigate conflicts. The certification must be signed and dated by an authorized official of the contractor, including the official's printed name and title.
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| File | Type | Posted |
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| Attachment 2 Certificate of Immigration Compliance.pdf | ||
| Attachment 4 - Contractor Rules of Behavior.pdf | ||
| Attachment 5 Updated Equipment List.xlsx | XLSX spreadsheet | |
| Attachment 1 Wage Determination 2015-4839.pdf | ||
| Solicitation 36C25026Q0276.pdf |
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Text version
Organizational Conflict of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION 36C25026Q0276
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that no individuals involved with 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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