ATTACHMENT D.5 - ORG CONFLICT OF INTEREST.pdf
PDF 129 KB Posted
- Solicitation number
- 36C24925R0028
About this file
This document is a Contractor Conflict of Interest Certification Statement for RFP No. 36C24925R0028, related to AngioInterventional Radiology Services for the Memphis VAMC Veterans Administration. The form requires the contractor to either certify that key personnel have no present, planned, or past financial, contractual, organizational, or other conflicts of interest, or to attach a detailed statement describing any such potential conflicts. The contractor must provide information about key personnel, consultants, and subcontractors, and may also include details about how they would mitigate any identified conflicts of interest. The document requires a signature from an authorized official certifying the accuracy of the conflict of interest disclosure.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT D.4 - PAST PERFORMANCE QUESTIONNAIRE.docx | DOCX document | |
| ATTACHMENT D.2 - RULES OF BEHAVIOR.pdf | ||
| ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.pdf | ||
| ATTACHMENT D.3 - CONTRACTOR CERTIFICATION.pdf | ||
| 36C24925R0028.docx | DOCX document |
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Text version
ATTACHMENT D.5 – 36C24925R0028
[CONTRACTOR NAME]
[ADDRESS]
RFP No.: 36C24925R0028
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel section of the solicitation 36C24925R0028 for Angio- Interventional Radiology 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 .