Attachment C_Vendor Conflicts of Interest.pdf
PDF 147 KB Posted
- Attached to
- Managed Information Technology Services
- Solicitation number
- RFP-12281
- Issued by
- Polk County, Florida
About this file
This document is a Vendor Conflicts of Interest Attestation form for RFP# 24-04 for Managed Information Technology Services issued by the Florida Department of Citrus. The attestation form requires vendors to disclose any potential conflicts of interest with Florida Department of Citrus employees, including current employees, those with 5% or more ownership in the vendor or its affiliates, and to confirm that their officers, directors, and agents will not create conflicts that could adversely impact contract performance.
The form provides a template for vendors to list any employees with connections to the Florida Department of Citrus, requiring disclosure of full legal names, position titles, and either positions held or percentage of ownership. By completing and signing this document, the vendor's authorized representative attests to their understanding and compliance with Chapter 112 of Florida Statutes regarding conflicts of interest in the procurement process for this information technology services contract.
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Text version
RFP# 24-04
Managed Information Technology Services
Attachment C: Vendor Conflicts of Interest Attestation 1 of 1
Attachment C: Vendor Conflicts of Interest Attestation
This solicitation is subject to Chapter 112, Florida Statutes. Respondents shall indicate whether or not any conflict exists regarding any Florida Department of Citrus employee.
I, _____________________________________ am the ________________________________ of
(Authorized Representative’s Name) (Title)
_______________________________________, (the “Vendor”), and am authorized to represent and
(Vendor’s Legal Name) contractually bind Vendor. Having been duly sworn, I do hereby attest, to the best of my knowledge and belief, the following:
• Vendor has disclosed all officers, directors, employees, other agents that are presently an employee of the Florida Department of Citrus; and
• Vendor has disclosed all employees that own, directly, or indirectly, an interest of five percent
(5%) or more in the respondent, or its affiliates; and
• Vendor’s officers, directors, employees, or other agents will not create a conflict in any manner or degree that will adversely impact the performance of the services required to be performed under the Contract.
Employee Disclosure:
Full Legal Name Position Title Disclosed Position Held or % of Ownership
Signature
Date
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