Attachment D.3 Org. Conflict of Interest.pdf
PDF 52 KB Posted
- Attached to
- Q201--NEW Dyersburg CBOC Services
- Solicitation number
- 36C24925R0056
About this file
This document is a Contractor Conflict of Interest Certification Statement for Solicitation #36C24925R0056 related to Dyersburg CBOC (Community-Based Outpatient Clinic) Services for the Lt. Col. Luke Weathers, Jr. VAMC (Veterans Administration Medical Center). The form provides two options for contractors: 1) certify that key personnel and employees have no present, past, or planned conflicts of interest relating to the services, or 2) attach a statement describing any potential organizational conflicts of interest. Contractors must also provide similar information for consultants and subcontractors, and may include details about how they would mitigate any potential conflicts of interest.
The document requires a certifying official to sign and date the form, acknowledging the organization's commitment to avoiding conflicts of interest in the contract with the Veterans Administration. The solicitation appears to be for medical services at a Veterans Affairs facility, with a focus on ensuring transparency and ethical considerations in the contractor selection process.
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Text version
Attachment D.3 Organizational Conflict of Interest 36C24925R0056
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C24925R0056
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 36C24925R0056 Dyersburg CBOC Services 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 Lt. Col.
Luke Weathers, Jr. 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 Lt. Col. Luke Weathers, Jr. 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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