Attachment 4 - Organizational Conflict of Interest.pdf
PDF 3 MB Posted
- Attached to
- NWI Offsite Pathology Services
- Solicitation number
- 36C26326R0063
About this file
This is an Organizational Conflict of Interest (OCI) Contractor Certification form required as Attachment 4 to a solicitation issued by the Nebraska-Western Iowa VA Health Care System. The form is a template designed for contractors to complete and submit with their proposals.
The certification requires the contractor to attest to one of two positions: either that no individuals involved with the solicitation have any present, planned, or past financial, contractual, organizational, or other conflicts of interest relating to the services to be provided; or alternatively, that conflicts exist and a detailed statement is attached describing all relevant facts concerning past, present, or currently planned interests and actual or potential organizational conflicts. When conflicts are disclosed, the contractor must provide similar statements for any consultants and subcontractors identified in the proposal that will provide services under the solicitation, and may include information demonstrating how the contractor's organizational or management systems would mitigate or avoid such conflicts. The form requires signature and date from a certifying official with their printed name and title. The contractor must complete header information including contractor name, address, and the applicable solicitation number.
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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 Nebraska-Western Iowa VA Health Care System 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 Nebraska- Western Iowa VA Health Care System 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 4: Organizational Conflict of Interest
| Text3: |
| Contractor Company: |
| Solicitation#: |
| Address: |
| No COI affirmation: Choice1 |
| Date7_af_date: |
File details come from the government source that posted it. Updated .