D.2 Organizational Conflict of Interest 36C24423R0132.pdf
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- Solicitation number
- 36C24423R0132
About this file
This document is an organizational conflict of interest certification statement template for solicitation number 36C24423R0132 regarding community-based outpatient clinic services for the Lebanon VA Medical Center. The template requires the contractor to certify that no individuals involved with the solicitation have any present, planned, or potential organizational conflicts of interest relating to the services requested. The contractor must also disclose any past conflicts of interest or provide an attached statement describing any relevant facts concerning past, present, or planned conflicts that could relate to the solicitation. Additionally, the contractor must provide similar statements for any consultants or subcontractors involved in the proposal. The certification must be signed and dated by an authorized official of the contracting organization.
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Organizational Conflict of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION #
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that no individuals involved with the solicitation [____Solicitation # and Service Type___] in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___[NAME OF VAMC] _________ Veterans Administration under the referenced solicitation.
None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the___NAME OF VAMC _________ Veterans Administration under the referenced solicitation.
OR
[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.
NAME OF CERTIFYING OFFICIAL
TITLE
SIGNATURE DATE
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