Conflict of Interest.pdf
PDF 179 KB Posted
- Attached to
- CEI Continuing Professional Services
- Solicitation number
- RFP 360 2026053 1
- Issued by
- Palm Beach County, Florida
About this file
This is a Conflict of Interest Disclosure Form required by Palm Beach County, Florida for consultants and annual consultants performing services on county projects. The form requires consultants to disclose any direct or indirect interests that could conflict with their performance of services for the county. Consultants must certify that they have no conflicting interests except as specifically listed on the form, and they must comply with Chapter 112, Part III of Florida Statutes and Section 2-441 et seq. of the Palm Beach County Code of Ethics. The form requires disclosure of the project name, project number, and the consultant's firm information, including the name, title, and signature of the authorized representative submitting the disclosure.
Consultants are obligated to promptly notify the county in writing via certified mail of any potential conflicts of interest that may arise in the future through prospective business associations, interests, or circumstances that could influence their judgment or quality of services. The county has sole discretion to determine whether a prospective business association or interest constitutes an unacceptable conflict, and consultants are prohibited from entering into any such arrangement if the county determines it would be conflicting. Misrepresentation on this disclosure form is considered an unethical business practice and grounds for sanctions against future business with Palm Beach County. The disclosure serves as a certification that all current and potential conflicts of interest have been identified and disclosed.
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Other files
| File | Type | Posted |
|---|---|---|
| Alternate Format Availability.pdf | ||
| Prime Firms SBE Past Participation Statement.docx | DOCX document | |
| Qualification Questionnaire Prime.pdf | ||
| Instructions for Completing a CCNA RFP.pdf | ||
| Conflict of Interest.docx | DOCX document | |
| OSBD Schedules and Instructions.pdf | ||
| RFI Form.pdf | ||
| Prime Firms SBE Past Participation Statement.pdf | ||
| RFI Form.docx | DOCX document | |
| Qualification Questionnaire Subconsultant.pdf | ||
| Disclosure of Ownership Interests.docx | DOCX document | |
| Commercial Non-discrimination.pdf | ||
| 2026053 - CCNA RFP Package - signed.pdf | ||
| Commercial Non-discrimination.docx | DOCX document | |
| Qualification Questionnaire Prime.docx | DOCX document | |
| Qualification Questionnaire Subconsultant.docx | DOCX document |
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Text version
CONFLICT OF INTEREST DISCLOSURE FORM
Project: ______________________________________________________
Project No.: _____________
CONSULTANT/ANNUAL CONSULTANT represents that it presently has no interest, either direct or indirect, which would or could conflict in any manner with the performance of services for the County, except as follows:
(Attach additional sheets as needed)
CONSULTANT/ANNUAL CONSULTANT further represents that it presently has no interest and shall acquire no interest which would conflict with performance of services solicited herein, as provided for in Chapter 112, Part III, Florida Statutes, and Section 2-441, et seq., the Palm Beach
County Code of Ethics. The CONSULTANT/ANNUAL CONSULTANT further represents that no person having any such conflict of interest shall be employed for said performance of services.
CONSULTANT/ANNUAL CONSULTANT shall promptly notify the COUNTY in writing by certified mail of all potential conflicts of interest that may arise in the future through any prospective business association, interest or other circumstance which may influence or appear to influence CONSULTANT’S/ANNUAL CONSULTANT’S judgment or quality of services being provided to the County. Such written notification shall identify the prospective business association, interest or circumstance, the nature of work that CONSULTANT/ANNUAL
CONSULTANT may undertake and request an opinion of the COUNTY as to whether the association, interest or circumstance would, in the opinion of the COUNTY, constitute an unacceptable conflict of interest if entered into by the CONSULTANT/ANNUAL
CONSULTANT.
If, in the sole opinion of the COUNTY, the prospective business association, interest or circumstance of CONSULTANT/ANNUAL CONSULTANT would constitute an unacceptable conflict of interest to the COUNTY, the COUNTY shall so state in the notification and the
CONSULTANT/ANNUAL CONSULTANT shall not enter into said association, interest or circumstance.
By signing below, CONSULTANT/ANNUAL CONSULTANT certifies that the information contained herein is true and correct and constitutes all current potential conflicts of interest which may influence or appear to influence CONSULTANT’S/ANNUAL CONSULTANT’S judgment or quality of services being provided to the County.
THIS DISCLOSURE is submitted by ________________________________________(name), as ____________________(title), of _____________________________________________(firm).
who hereby certifies that the information stated above is true and correct. Further, it is hereby acknowledged that any misrepresentation by the CONSULTANT/ANNUAL CONSULTANT on this Disclosure is considered an unethical business practice and is grounds for sanctions against future County business with the CONSULTANT/ANNUAL CONSULTANT.
(Print Name and Title) (Signature) (Date)
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| CONFLICT OF INTEREST DISCLOSURE FORM |
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