Conflict_of_Interest_Form.cleaned.pdf
PDF 143 KB Posted
- Attached to
- LIME SLAKER REPLACEMENT PROJECT
- Solicitation number
- RFQ/P NO. 3095
- Issued by
- Santa Barbara County, Los Angeles City, California
About this file
This is a Conflict-of-Interest Declaration Form issued by the City of Lompoc, California Purchasing Department in connection with the Lime Slaker Replacement Project. The form requires City employees involved in the procurement process to declare that they have no financial, personal, or other interests that could create a conflict of interest in relation to their professional duties. Employees must confirm they have no direct or indirect financial interests in entities or individuals that could influence their decisions, no personal relationships or affiliations that could compromise impartiality, and commit to disclosing any potential conflicts of interest that may arise in the future. The declaration requires a wet signature on the original document, which may be faxed or scanned, and is based on City ordinance 3.36.080 and applicable provisions of California Government Code sections 87100 and 1090.
The form serves as a compliance mechanism to ensure the integrity of the procurement process for the Lime Slaker Replacement Project, which involves the upgrade of two lime slaker units at the City's Water Treatment Plant. City employees are prohibited from participating in any solicitation or selection processes for procurements when they have a relationship with a vendor or proposer that would violate conflict-of-interest provisions under state law or the City's Conflict of Interest Code. All personnel involved in evaluating proposals must complete and sign the declaration form prior to engaging in procurement activities related to this project.
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Text version
No Conflict-of-Interest Declaration Form
City of Lompoc, Purchasing Department, 100 Civic Center Plaza, Lompoc, CA 93436 (805)875-8000 fax (805)875-8633 purchasing@ci.lompoc.ca.us
Name: [Your Full Name] Date: [Insert Date]
Position/Title: [Your Job Title]
Department/Organization: [Your Department/ Organization Name]
I, [Your Full Name], hereby declare that I have no financial, personal, or other interests that could be perceived as a conflict of interest in relation to my professional duties and responsibilities at [Your Organization Name].
I confirm that:
1. I do not have any direct or indirect financial interests in any entities or individuals that could influence my decisions or actions.
2. I do not have any personal relationships or affiliations that could compromise my impartiality.
3. I will disclose any potential conflicts of interest that may arise in the future.
By signing this declaration, I affirm that the information provided is true and accurate to the best of my knowledge.
Signature: ___________________________ Date: _______________________________
Note: Wet signature required (Original) can be faxed or scanned by all parties Fill in highlighted areas and then sign on unhighlighted line.
§ 3.36.080Conflict of Interest.
No City employee shall participate in the solicitation or selection processes for any procurement of any kind when that employee has a relationship with a vendor or proposer which would subject that employee to the prohibition of Government Code section 87100 or 1090 or any other applicable provision of law or the City's Conflict of
Interest Code.
(Prior code § 2633; Ord. 1637(17) § 1)
File details come from the government source that posted it. Updated .