D.3 - Organizational Conflict of Interest.docx

This is an Organizational Conflict of Interest Certification Statement template required for submission under solicitation 36C24926R0040 for Perfusionist Services at the Tennessee Valley Healthcare System (TVHS) Veterans Administration Medical Center (VAMC) in Nashville, Tennessee.

The certification statement requires the contractor to declare whether they, their employees, consultants, and subcontractors have any present, past, or currently planned financial, contractual, organizational, or other interests that would create actual or potential organizational conflicts of interest related to the services to be provided. Contractors must select one of three options: certify no conflicts of interest exist; certify that no past conflicts exist; or provide a detailed statement describing all relevant facts concerning any conflicts and explaining how their organizational or management systems would mitigate such conflicts. The form requires signature, date, and identification of the certifying official and title. This certification applies to all individuals and entities involved with the solicitation, including any consultants and subcontractors that will provide services under the contract.