Attachment D.2 - Contractor Organizational Conflict of Interest.pdf
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- Solicitation number
- 36C24923R0047
About this file
This document contains a template certification statement and organizational conflict of interest disclosure for contractors responding to solicitation number 36C24923R0047 for community based outpatient clinic services in Helena, Arkansas. The solicitation was issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9. The template requires the contractor to certify that its key personnel assigned to the solicitation have no present or currently planned conflicts of interest, or to provide a statement describing any past, present or potential organizational conflicts. Contractors must also provide conflict of interest disclosures for any consultants or subcontractors. The purpose is to avoid or mitigate any actual or potential organizational conflicts of interest relating to the services to be provided under the solicitation.
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Attachment D.2 – Contractor Organizational Conflict of Interest
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
36C24923R0047 - Helena CBOC
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