ATTACHMENT D.5 - ORG CONFLICT OF INTEREST.pdf

172 KB Posted

Attached to
Q523--Competitive | Plastic Surgery | 614 POP: 10/1/25 to 9/30/30 614-26-1-039-0003
Solicitation number
36C24925R0054
Issued by

About this file

Written by GovTribe AI ·

This document is a Contractor Conflict of Interest Certification Statement for RFP No. 36C24925R0054, relating to Plastic Surgery Physician Services for the Memphis Veterans Administration Medical Center (VAMC). The form requires the contractor to certify that key personnel have no present, planned, or past conflicts of interest relating to the services to be provided.

The document provides two options for certification: 1) affirming no conflicts of interest exist for individuals listed in the Key Personnel section, or 2) attaching a detailed statement describing any past, present, or potential conflicts of interest. If selecting the second option, the contractor must provide information about any financial, contractual, organizational, or other interests that could constitute a conflict, including details for consultants and subcontractors. The form must be signed by an authorized official, with space provided for the name, title, and signature date.

View the file

Other files

File Type Posted
ATTACHMENT D.2 - RULES OF BEHAVIOR.pdf PDF
ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.pdf PDF
ATTACHMENT D.6 - PAST PERFORMANCE QUESTIONNAIRE.docx DOCX document
ATTACHMENT D.4 - STATEMENT OF COMMITMENT AND UNDERSTANDING.pdf PDF
36C24925R0054.docx DOCX document
ATTACHMENT D.3 - CONTRACTOR CERTIFICATION.pdf PDF

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

ATTACHMENT D.5 – 36C24925R0054

[CONTRACTOR NAME]

[ADDRESS]

RFP No.: 36C24925R0054

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel section of the solicitation 36C24925R0054 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 .