Attachment III - Conflict of Interest Statement.docx
DOCX document 12 KB Posted
- Attached to
- H365--RSO Services and Equipment Testing
- Solicitation number
- 36C25021Q0601
About this file
This document contains a federal contract opportunity for radio frequency safety services and equipment testing. The Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 is soliciting quotes for radio frequency safety services and equipment testing at the John D. Dingell VA Medical Center in Detroit, Michigan. The anticipated period of performance is from July 29, 2021 to July 28, 2022 with four optional one-year extension periods. Quotes are due by the date and time specified in the SF1449 and must be submitted via email to the contracting specialist at jeremy.boston@va.gov as a PDF, Word, or Excel file less than 10MB in size. The requirement is set aside for small businesses with a NAICS code of 541990.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25021Q0601 0001.docx | DOCX document | |
| Attachment II - Equipment List - Updated 06152021.xlsx | XLSX spreadsheet | |
| Attachment III - NHPP Permit.pdf | ||
| 36C25021Q0601 0001_1.docx | DOCX document | |
| Attachment V - Contractor Cert of Compliance Immigration.pdf | ||
| Attachment II - Equipment List.xlsx | XLSX spreadsheet | |
| Attachment VI - BCVAMC Medical Staff Bylaws.pdf | ||
| Attachment I - Wage Determination 2015-4839.pdf | ||
| 36C25021Q0601_1.docx | DOCX document | |
| 36C25021Q0601.docx | DOCX document | |
| Attachment IV - Contractor ROB.pdf |
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Text version
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C25019Q0473
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that the individuals who will be presented as candidates for Key Personnel and Temporary Emergency Substitutions section of the solicitation RFQ 36C25019Q0473 2.8 FTE MOD Physicians, 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 Battle Creek VAMC Veterans Administration under the referenced solicitation.
None of the candidates submitted in response to the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual organizational conflicts of interest relating to the services to be provided to the Battle Creek 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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