ATTACHMENT D.5 - ORG CONFLICT OF INTEREST.pdf
PDF 130 KB Posted
- Solicitation number
- 36C24925R0031
About this file
This document is a Contractor Conflict of Interest Certification Statement for RFP No. 36C24925R0031, related to Plastic Surgery Physician Services for the Memphis Veterans Administration Medical Center (VAMC). The form requires the contractor to either certify that key personnel have no present, planned, or past conflicts of interest relating to the services, or to attach a detailed statement describing any potential conflicts of interest. The document provides two checkbox options: one for a clean certification of no conflicts, and another allowing the contractor to provide a comprehensive explanation of any relevant interests or potential organizational conflicts that might impact the service provision.
The certification form applies to the referenced solicitation for Plastic Surgery Physician Services and requires the contractor to disclose any financial, contractual, organizational, or other interests that could potentially compromise the independence or objectivity of the key personnel, employees, consultants, or subcontractors involved in the project. The form includes spaces for the name and signature of the certifying official, emphasizing the need for transparency and ethical compliance in the federal contracting process.
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Other files
| File | Type | Posted |
|---|---|---|
| S05 Vendor Questions.docx | DOCX document | |
| 36C24925R0031 0001.docx | DOCX document | |
| 36C24925R0031.docx | DOCX document | |
| ATTACHMENT D.6 - PAST PERFORMANCE QUESTIONNAIRE.docx | DOCX document | |
| ATTACHMENT D.3 - CONTRACTOR CERTIFICATION.pdf | ||
| ATTACHMENT D.2 - RULES OF BEHAVIOR.pdf | ||
| ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.pdf | ||
| ATTACHMENT D.4 - STATEMENT OF COMMITMENT AND UNDERSTANDING.pdf |
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Text version
ATTACHMENT D.5 – 36C24925R0031
[CONTRACTOR NAME]
[ADDRESS]
RFP No.: 36C24925R0031
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel section of the solicitation 36C24925R0031 for Plastic Surgery Physician Services 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 Memphis 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 Memphis 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
ATTACHMENT D.5 – 36C24924R0034
File details come from the government source that posted it. Updated .