ATTACHMENT 6 - ORG. COI.pdf
PDF 92 KB Posted
- Solicitation number
- 36C24821R0015
About this file
This document contains an organizational conflict of interest certification statement template for a federal solicitation. The solicitation is for board certified therapeutic medical physicist services to be provided to Veterans Integrated Service Network 8 of the Department of Veterans Affairs. Offerors must disclose any past, present, or planned interests or conflicts of interest that may relate to the services solicited, including those of any consultants, subcontractors, or key personnel proposed. Offerors may also provide information on how their organizational system would avoid or mitigate potential conflicts of interest.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24821R0015 0002.docx | DOCX document | |
| 36C24821R0015 0001.docx | DOCX document | |
| ATTACHMENT 5 MEDICAL STAFF BYLAWS.pdf | ||
| ATTACHMENT 2 QUALITY ASSURANCE SURVIELANCE PROGRAM (QASP).pdf | ||
| ATTACHMENT 1 PAST PERFORMANCE QUESTIONAIRE.pdf | ||
| ATTACHMENT 4 CONTRACTOR RULES OF BEHAVIOR.pdf | ||
| ATTACHMENT 3 CONT. CERT. IMMIGRATION AND NATIONALITY ACT.pdf | ||
| 36C24821R0015_4.docx | DOCX document |
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Text version
ATTACHMENT D.6 – ORGANIZATIONAL CONFLICTS OF INTEREST
RFP 36C24821R0015
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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