ATTACHMENT 5 ORGANIZATIONAL CONFLICTS OF INTEREST.pdf
PDF 71 KB Posted
- Attached to
- Q522--Therapeutic Medical Physicist
- Solicitation number
- 36C24822Q1383
About this file
This document provides an organizational conflicts of interest certification statement template for contractors responding to solicitation number 36C24822Q1383 from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8 for therapeutic medical physicist services. The template requires contractors to certify that their key personnel listed in the solicitation have no present, planned, or past financial, contractual, organizational, or other conflicts relating to providing the solicited services, or to submit a statement describing any such conflicts. Contractors must also provide conflict of interest certifications for any consultants or subcontractors. The purpose is to avoid or mitigate potential organizational conflicts of interest for the therapeutic medical physicist services solicited.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24822Q1383 0002.docx | DOCX document | |
| 36C24822Q1383 0001.docx | DOCX document | |
| ATTACHMENT 2 QUALITY ASSURANCE SURVIELANCE PROGRAM (QASP).pdf | ||
| ATTACHMENT 4 CONTRACTOR RULES OF BEHAVIOR.pdf | ||
| ATTACHMENT 3 CONT. CERT. IMMIGRATION AND NATIONALITY ACT.pdf | ||
| ATTACHMENT 1 PAST PERFORMANCE QUESTIONAIRE.pdf | ||
| ATTACHMENT 6 - SMALL BUSINESS SUB-CONTRATING PLAN.pdf | ||
| 36C24822Q1383_1.docx | DOCX document |
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Text version
ATTACHMENT D.5 - ORGANIZATIONAL CONFLICTS OF INTEREST
RFQ 36C24822Q0477
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 L_Solicitation # and Service Type__J 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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