Conflict_of_Interest_Form.pdf
PDF 143 KB Posted
- Attached to
- Office Supplies
- Solicitation number
- 2025-RFQ-023DW
- Issued by
- Santa Barbara County, California
About this file
The document is a No Conflict-of-Interest Declaration Form issued by the City of Lompoc's Purchasing Department, located at 100 Civic Center Plaza in Lompoc, California. The form is a standard template designed for individuals to declare that they have no financial, personal, or other interests that could be perceived as a conflict of interest in relation to their professional duties and responsibilities.
The form requires the individual to confirm three key points: (1) they do not have any direct or indirect financial interests that could influence their decisions, (2) they do not have personal relationships or affiliations that could compromise their impartiality, and (3) they will disclose any potential conflicts of interest that may arise in the future. The document also includes a municipal code section (§ 3.36.080) that prohibits city employees from participating in procurement processes where they have a relationship with a vendor or proposer that would violate government conflict of interest regulations. A wet signature is required, and contact information for the Lompoc Purchasing Department is provided at the bottom of the form.
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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) mailto:purchasing@ci.lompoc.ca.us
File details come from the government source that posted it. Updated .