D.3 Attachment C - Organizational Conflict of Interest.docx
DOCX document 32 KB Posted
- Solicitation number
- 36C24925R0021
About this file
This is an Organizational Conflict of Interest (OCI) certification form related to solicitation 36C24925R0021 for Urology Cryoablation Services at the Lt. Col Luke Weathers Jr., VAMC Veterans Administration. The form requires contractors to certify whether they have any present, past, or planned interests (financial, contractual, organizational) that could create conflicts of interest in providing the solicited services.
The form provides three certification options: 1) confirming no present/planned conflicts exist, 2) confirming no past conflicts exist, or 3) attaching a detailed statement describing any relevant past, present, or planned interests that could create conflicts. Contractors must provide this information for themselves and any subcontractors or consultants who will support the contract. The form requires signature by an authorized certifying official.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24925R0021 0001.docx | DOCX document | |
| D.1 Attachment A - QASP.pdf | ||
| 36C24925R0021.docx | DOCX document | |
| D.4 Attachment D - Past Performance Survey.docx | DOCX document | |
| D.2 Attachment B - Contractor Certification of Immigration.docx | DOCX document |
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Text version
D.3 Attachment C - Organizational Conflict of Interest 36C24925R0021
CONTRACTOR NAME:
ADDRESS:
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ X] represents that no individuals involved with the solicitation
| 36C24925R0021 Urology Cryoablation Services | 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 | Lt. Col Luke Weathers Jr., 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 | Lt. Col Luke Weathers Jr., 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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