ATTACHMENT D.5 - ORG CONFLICT OF INTEREST.docx
DOCX document 20 KB Posted
- Solicitation number
- 36C24924R0034
About this file
This document is a Conflict of Interest Certification Statement for a federal contract opportunity related to providing Emergency Department Physician services to the Tennessee Valley Healthcare System (TVHS) VAMC Veterans Administration. The contractor certifies that the individuals listed as key personnel have no present or planned financial, contractual, organizational, or other conflicts of interest related to the services to be provided under the referenced solicitation number 36C24924R0034. The contractor notes that they may provide additional statements describing any relevant facts about past, present, or planned interests or conflicts of interest. The federal contract opportunity is for Locum Tenens Emergency Room Physician Services with a period of performance from 10/01/2024 to 09/30/2029, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 9.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24924R0034 0001.docx | DOCX document | |
| ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.docx | DOCX document | |
| ATTACHMENT D.4 - PAST PERFORMANCE QUESTIONNAIRE.docx | DOCX document | |
| ATTACHMENT D.3 - CONTRACTOR CERTIFICATION.docx | DOCX document | |
| ATTACHMENT D.2 - RULES OF BEHAVIOR.docx | DOCX document | |
| 36C24924R0034.docx | DOCX document |
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ATTACHMENT D.5 – 36C24924R0034
[CONTRACTOR NAME]
[ADDRESS]
RFP No.: 36C24924R0034
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 36C24924R0034 for Emergency Department Physicians 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 Tennessee Valley Healthcare System (TVHS) 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 Tennessee Valley Healthcare System (TVHS) 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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