COI_EOA_PC_Fillable.pdf
PDF 75 KB Posted
- Attached to
- Tree Planting: Centreville YMCA
- Solicitation number
- BPM057808
- Issued by
- Queen Anne's County, Maryland
About this file
This is a Conflict of Interest Disclosure, Employment of Aliens Statement, and Political Contribution Reporting Requirements form required by the County Commissioners of Queen Anne's County, Maryland for vendors participating in the bid process. The form applies to the Tree Planting: Centreville YMCA contract opportunity, which seeks electronic bids for tree stock, planting, maintenance, and monitoring services to be performed at YMCA of Chesapeake, Inc./Centreville Branch located at 210 Vincit Street, Centreville, Maryland. Qualified bidders must submit proposals by July 22, 2026 at 1:00 PM Local Time through the online portal at https://qacmd.seamlessdocs.com/ng/fa/YMCATrees. Bids will be opened publicly and read aloud at that time, with contract award going to the lowest responsive, responsible bidder.
Bidders must certify under penalty of perjury their conflict of interest status by selecting appropriate disclosure boxes indicating either no conflicts of interest, potential conflicts requiring detailed explanation, or current involvement in situations that may constitute conflicts. Additionally, vendors must comply with all applicable laws and regulations regarding employment of aliens, with non-compliance constituting material breach subject to contract termination. Bidders must also be aware that any person doing business with the government entity may be subject to political contribution reporting requirements under Title XIV of Maryland's Election Law. The form requires submission of signature, printed name, company or organization name, address, phone number, and date.
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Text version
CONFLICT OF INTEREST DISCLOSURE EMPLOYMENT OF ALIENS STATEMENT POLITICAL
CONTRIBUTION REPORTING REQUIREMENTS FORM
In connection with the undersigned s participation in the bid process or request for proposals being considered by the County Commissioners of Queen Anne s County the County the undersigned does affirm under the penalties of perjury as follows
I have reviewed the materials provided by the County in connection with my proposed bid or proposal and reviewed such records of my company and business as necessary to make the following statements
Check all appropriate boxes o To the best of my knowledge and belief neither I the company identified below nor any employee of the company have been involved or are presently involved in any situations or actions that might be regarded as an actual or potential conflict of interest in the event of a successful bid or award o It appears that I the company identified below or an employee of the company have been involved in some situations or actions that might be regarded as a potential conflict of interest should I submit the successful bid or proposal Details of such situations and or actions are hereby attached to this form attach additional sheet s o The following situations or actions in which I my company or an employee of the company are presently involved might be regarded as a potential conflict of interest if I submit the successful bid or proposal attach additional sheet s o I have attached a list of all present contracts between the company named below and the
County
Furthermore vendors providing goods or services to Queen Anne s County Government as a condition of doing business with the County are required to comply with all applicable laws and regulations relating to the employment of aliens
Should vendors providing goods or services to Queen Anne s County fail to comply with applicable laws and regulations relating to the employment of aliens such failure shall constitute a material breach of the vendor s contractual relationship with Queen Anne s County and the County may take all reasonable steps to terminate the County s contractual relationship with the vendor If you have questions please consult the County Department that manages your vendor contract
Notice of reporting requirements Any person doing business with a government entity may be subject to the political contribution reporting requirements of Title XIVof the Election law Article of the
Annotated Code of Maryland
Signature Name please print
Company Organization
Address
Phone Number
Date
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| Check Box0: Off |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
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