CONFLICT_OF_INTEREST_STATEMENT_-_VENDOR.pdf
PDF 278 KB Posted
- Attached to
- Airport General Engineering Consultant
- Solicitation number
- RFQ-019-2022
- Issued by
- Clay County, Florida
About this file
The document is a Conflict of Interest Statement for the City of Lake City, Florida, related to the RFQ-019-2022 for an Airport General Consultant contract. The statement is designed to be completed by a proposing entity seeking to provide professional services for the Lake City Gateway Airport (LCQ), with the document requiring detailed disclosures about the proposing organization's business relationships, potential conflicts, and commitment to competitive and ethical bidding practices.
The form requires the proposing entity to certify that they are submitting only one proposal, have no financial interests in competing proposals, have not engaged in collusive pricing practices, are not currently suspended from contract work by any government agency, and have no potential conflicts of interest. Additionally, the statement requires confirmation that no members of the organization's ownership, management, or staff are applying for city employment, seeking elected positions, or have vested interests in the City of Lake City. The affiant must also commit to immediately notifying the city if any conflict of interest is identified during the service provision process.
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Text version
CONFLICT OF INTEREST STATEMENT
STATE OF FLORIDA, CITY OF ___________________________________________
Before me, the undersigned authority, personally appeared____________________, who was duly sworn deposes and states:
1. I am the ________________________of_________________________________ with a local office in _______________________________and principal office in
___________________________and principal office in ____________________.
City & State City & State
2. The above named entity is submitting a Proposal for the City of Lake City RFQ-019-2022 described as
AIRPORT GENERAL CONSULTANT
3. The Affiant has made diligent inquiry and provides the information contained in the Affidavit based upon his/her own knowledge.
4. The Affiant states that only one submittal for the above proposal is being submitted and that the above named entity has no financial interest in other entities submitting proposals for the same project.
5. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection with the entity’s submittal for the above proposal. This statement restricts the discussion of pricing data until the completion of negotiations if necessary and execution of the Contract for this project.
6. Neither the entity not its affiliates, nor any one associated with them, is presently suspended or otherwise ineligible from participation in contract letting by any local, State, or Federal Agency.
7. Neither the entity nor its affiliates, nor any one associated with them have any potential conflict of interest due to any other clients, contracts, or property interests for this project.
8. I certify that no member of the entity’s ownership or management is presently applying for an employee position or actively seeking an elected position with the City of Lake City.
9. I certify that no member of the entity’s ownership or management, or staff has a vested interest in any aspect of the City of lake City.
10. In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above named entity, will immediately notify the City of Lake City.
DATED this _______day of ___________ 2022
(Affiant)
Typed Name and Title
Sworn to and subscribed before me this _______day of ____________2006.
Personally Known_________ Or produced identification___________.
Identification type:_________________________________________
Notary Public-State of ______________________________________
Printed, typed, or stamped commissioned name of notary public.
My commission expires________________.
THIS FORM MUST BE INCLUDED WITH YOUR SUBMITTAL.
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