CHP_78V_Conflict.pdf.pdf
PDF 1 MB Posted
- Attached to
- RECAST SOFTWARE 3 YEAR AGREEMENT
- Solicitation number
- 0000040444
- Issued by
- Sacramento County, San Francisco City, California
About this file
This is a Conflict of Interest and Confidentiality Statement form issued by the State of California Department of California Highway Patrol (CHP), form number CHP 78V (Rev. 4-11). The form is mandatory for all contractors and vendors to complete and submit prior to commencing contract services or delivering requested commodities. Failure to submit the completed statement before work begins is grounds for contract termination. The statement applies to the related RECAST Software 3-Year Agreement opportunity with a due date of October 6, 2026, at 3:00 PM PDT. Procurement inquiries should be directed to De Anne Campagna at 916.843.3620 or deanne.campagna@chp.ca.gov, with backup contact Ayesha Brown at 916-843-3628 or ayesha.brown@chp.ca.gov.
The form requires authorized company representatives to warrant that the company and its employees have no conflicting personal or financial interests, past employment, or activities incompatible with the contract. Contractors must refrain from accepting any gifts, benefits, gratuities, or considerations from associated parties throughout the contract duration and must restrict access to state-provided materials to only authorized employees. All confidential financial, statistical, personal, technical, and media-related data must be protected and returned or destroyed in accordance with Federal Information Security Management Act (FISMA) and National Institute of Standards and Technology (NIST) Special Publication 800-36 standards. Contractors must provide written certification of material destruction and prohibit third-party access to confidential information without prior written state authorization. Non-compliance subjects contractors to criminal and civil liabilities and damages to the state.
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Text version
Chp 78V_1121.pdf
Safety, Service, and Security An Internationally Accredited Agency
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT - VENDOR
CHP 78V (Rev. 4-11) OPI 076
It is a mandatory requirement for the contractor/vendor to complete and submit the Conflict of Interest and Confidentiality Statement prior to commencing contract services and/or delivering requested commodities. Failure to complete and submit the Conflict of Interest and Confidentiality Statement prior to commencement of work and/or delivery of requested commodities will be grounds for contract termination.
As an authorized representative and/or corporate officer of the company named below, I warrant my company and its employees have no personal or financial interest and no present or past employment or activity which would be incompatible with participating in any activity related to this contract. For the duration of this contract, I warrant my company and its employees will not accept any gift, benefit, gratuity or consideration, or begin a personal or financial interest in a party who is associated with this contract.
I warrant my company and its employees not to disclose any financial, statistical, personal, technical, media-related, and all other data and information made available to use by the state for the purpose of providing services to the California Highway Patrol (CHP) in conjunction with the contract identified above. I warrant that only those employees who are authorized and required to use such materials will have access to them. Authorization documentation must be provided to the CHP prior to the start of the contract.
I further warrant that all materials provided by the state will be returned promptly after use; all copies or derivations of the materials will be physically and/or electronically sanitized at a minimum in accordance with the Federal Information Security Management Act (FISMA), National Institute of Standard Technology (NIST), 43 NIST Special Publication 800-36. I will include, with the returned materials, a letter attesting to the complete return of materials and documenting the destruction of copies and derivations. Failure to so comply will subject my company to criminal and civil liabilities, including all damages to the state. I authorize the state to inspect and verify the destruction document(s) as described above.
I warrant that my company will not enter into any agreements or discussions with a third party concerning such materials prior to receiving written confirmation from the state that such third party has an agreement with the state similar in nature to this one. I agree to immediately advise the CHP contract coordinator of any person(s) who has access to project confidential information and intends to disclose that information in violation of this agreement.
NAME OF COMPANY
NAME OF COMPANY REPRESENTATIVE TITLE
DATESIGNATURE OF COMPANY REPRESENTATIVE
OPI CONTRACT/REQUISITION NUMBER
Chp 78V_1121.pdf Safety, Service, and Security An Internationally Accredited Agency
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT - VENDOR
CHP 78V (Rev. 4-11) OPI 076 It is a mandatory requirement for the contractor/vendor to complete and submit the Conflict of Interest and Confidentiality Statement prior to commencing contract services and/or delivering requested commodities. Failure to complete and submit the Conflict of Interest and Confidentiality Statement prior to commencement of work and/or delivery of requested commodities will be grounds for contract termination.
As an authorized representative and/or corporate officer of the company named below, I warrant my company and its employees have no personal or financial interest and no present or past employment or activity which would be incompatible with participating in any activity related to this contract. For the duration of this contract, I warrant my company and its employees will not accept any gift, benefit, gratuity or consideration, or begin a personal or financial interest in a party who is associated with this contract.
I warrant my company and its employees not to disclose any financial, statistical, personal, technical, media-related, and all other data and information made available to use by the state for the purpose of providing services to the California Highway Patrol (CHP) in conjunction with the contract identified above. I warrant that only those employees who are authorized and required to use such materials will have access to them. Authorization documentation must be provided to the CHP prior to the start of the contract.
I further warrant that all materials provided by the state will be returned promptly after use; all copies or derivations of the materials will be physically and/or electronically sanitized at a minimum in accordance with the Federal Information Security Management Act (FISMA), National Institute of Standard Technology (NIST), 43 NIST Special Publication 800-36. I will include, with the returned materials, a letter attesting to the complete return of materials and documenting the destruction of copies and derivations. Failure to so comply will subject my company to criminal and civil liabilities, including all damages to the state. I authorize the state to inspect and verify the destruction document(s) as described above.
I warrant that my company will not enter into any agreements or discussions with a third party concerning such materials prior to receiving written confirmation from the state that such third party has an agreement with the state similar in nature to this one. I agree to immediately advise the CHP contract coordinator of any person(s) who has access to project confidential information and intends to disclose that information in violation of this agreement.
CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT - VENDOR
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