Conflict of Interest.pdf
PDF 179 KB Posted
- Solicitation number
- RFP 360 2026052 3
- Issued by
- Palm Beach County, Florida
About this file
This is a Conflict of Interest Disclosure Form required for consultants and annual consultants performing services for Palm Beach County, Florida, in connection with a Street Lighting Professional Continuing Services Contract. The form mandates that consultants certify they have no direct or indirect interests that would conflict with performance of services for the County, except as explicitly disclosed. Consultants must represent compliance with Chapter 112, Part III of Florida Statutes and Section 2-441 et seq. of the Palm Beach County Code of Ethics, and certify that no employees with conflicting interests will be engaged for the work. The form requires consultants to promptly notify the County in writing by certified mail of any potential conflicts of interest that may arise during performance, including prospective business associations or circumstances that could influence professional judgment or service quality.
The disclosure form establishes that misrepresentation constitutes an unethical business practice subject to sanctions against future County business with the consultant. Upon written notification of potential conflicts, the County will provide an opinion on whether the prospective association or circumstance would constitute an unacceptable conflict; if the County determines it would be unacceptable, the consultant must not enter into that association or circumstance. The form requires certification by the consultant representative, including printed name, title, signature, and date, affirming that all information is true and correct and represents all current potential conflicts of interest that may influence the consultant's judgment or quality of services to Palm Beach County.
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Other files
| File | Type | Posted |
|---|---|---|
| RFI Form.docx | DOCX document | |
| 2026052 RFP Package.pdf | ||
| Prime Firms SBE Past Participation Statement.pdf | ||
| 2026052 - Update 1.pdf | ||
| Qualification Questionnaire Subconsultant.pdf | ||
| RFI Form.pdf | ||
| Qualification Questionnaire Prime.pdf | ||
| 2026052 Pre Proposal Sign In Sheet.pdf | ||
| OSBD Schedules and Instructions.pdf |
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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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