COI_EOA_PC_Fillable.pdf
PDF 75 KB Posted
- Attached to
- White Marsh Park Comfort Station
- Solicitation number
- BPM054342
- 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 submitted to the County Commissioners of Queen Anne's County, Maryland in connection with bidding on the White Marsh Park Comfort Station construction project. The comfort station will be constructed at White Marsh Park, located at 200 Bloomfield Farm Lane, Centreville, Maryland 21617. Electronic bids for construction services are due to the Department of Parks and Recreation, 1945 4H Park Road, Centreville, Maryland 21617 by January 15, 2026 at 1:00 pm local time, at which point bids will be opened publicly and read aloud. The contract will be awarded to the lowest responsive and responsible bidder.
The form requires bidders to disclose any actual or potential conflicts of interest, provide a list of all present contracts with Queen Anne's County, and attest to compliance with applicable laws and regulations regarding employment of aliens. Vendors providing goods or services to the county must comply with all applicable employment laws, and failure to do so constitutes material breach of contract and may result in contract termination. Additionally, any person doing business with the government entity may be subject to political contribution reporting requirements under Title XIV of the Election Law, Article of the Annotated Code of Maryland. The form serves as a disclosure and attestation document that must be completed and signed by the bidder or authorized company representative.
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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
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