CONTRACTOR_CONFLICT_OF_INTEREST_DISCLOSURE_FORM.pdf

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS 96th TEST WING (AFMC)

EGLIN AIR FORCE BASE FLORIDA

CONTRACTOR CONFLICT OF INTEREST DISCLOSURE FORM

Section 1: General Information

Contractor Employee Name: [Insert Full Name]

Position / Title: [Insert Position Title]

Employer (Company Name): [Insert Prime/Subcontractor Company Name]

Assigned Program / Project: [Insert Project Name]

Contract / Solicitation Number: [Insert Contract Number]

Date of Submission: [Insert Date]

Section 2: Conflict of Interest Questionnaire

Please review each question carefully and check the appropriate box. If you answer "YES" to any question, you must provide a detailed explanation in Section 3.

Question YES NO

1. Financial Interests: Do you, your spouse, or any member of your immediate household hold a financial interest (e.g., stocks, options, ownership) in an entity that is currently bidding on, contracting with, or acting as a subcontractor for this project?

2. Prior Government Service: Have you served as a government employee or active-duty military member within the past two (2) years? If yes, did you participate personally and substantially in acquisition, procurement, or source selection involving this contract or program?

3. Employment Negotiations: Are you currently seeking, negotiating, or do you have any arrangement concerning prospective employment or business relationships with any other organization associated with this contract?

4. Personal Relationships: Do you have any personal or family relationships with government officials, contracting officers, or employees of other contractors involved in this program that could create the appearance of favoritism or bias?

5. Unequal Access to Information: Through your work, do you have access to non-public, proprietary, or source selection sensitive information that could give your employer or another entity an unfair competitive advantage?

6. Gifts & Travel: Have you accepted any gifts, gratuities, entertainment, or travel from any entity or individual doing business with or seeking to do business under this contract?

Section 3: Specific Disclosures & Certifications

Corporate Interest Disclaimer: [Insert Prime/Subcontractor Company Name]

The following statement is formally entered into this record regarding organizational conflicts of interest (OCI) under FAR Subpart 9.5:

[Insert Prime/Subcontractor Company Name] has no financial or other interests in the outcome of the proposal. Neither [Insert Prime/Subcontractor Company Name], nor its subsidiaries, affiliates, or designated project personnel, possess any direct or indirect financial stake, organizational bias, or proprietary interest in the final selection, award, or outcome of this proposal. [Insert Prime/Subcontractor Company Name] remains a neutral, objective, and independent entity for the duration of this performance.

Section 4: Certification & Signature

I hereby certify that the information provided in this form is, to the best of my knowledge and belief, true, accurate, and complete.

I agree to immediately disclose to my employer and the appropriate contracting authorities any potential or actual conflicts of interest that may arise during the performance of this contract. I understand that failing to disclose a conflict or providing false information may result in administrative action, including removal from the contract or termination of employment.

Employee Signature: ________________________________

Date: _______________

[Insert Prime/Subcontractor Company Name] Authorized Representative Signature:

Title: _______________