D.3 Organizational Conflict of Interest.pdf
PDF 148 KB Posted
- Attached to
- Q509--589A7 | WI | NEPHROLOGY PHYSICIAN SERVICES BASE + 4OY | CO MICHAEL CARSON (VA-25-00091098)
- Solicitation number
- 36C25527Q0002_1
About this file
This is a Contractor Conflict of Interest Certification Statement form for solicitation 36C25527Q0002 issued by the Robert J. Dole VA Medical Center (VAMC) under the Veterans Administration for Nephrology Physician Services.
The form requires the contractor to certify either that no individuals involved with the solicitation have any present, past, or currently planned financial, contractual, organizational, or other interests that would create actual or potential organizational conflicts of interest relating to the services to be provided, or to attach a detailed statement describing all relevant facts concerning any such conflicts. If conflicts exist, the offeror must provide the same conflict of interest information for any consultants and subcontractors identified in its proposal that will provide services under the solicitation, and may include relevant facts demonstrating how its organizational and management systems or other actions would avoid or mitigate any actual or potential conflicts of interest. The form requires signature, title, and date from the certifying official and includes fields for contractor name and address.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25527Q0002 0001.pdf | ||
| D.1 Quality Assurance Surveillance Program.pdf | ||
| D.2 Contractor Rules of Behavior.pdf | ||
| D.4 Immigration and Nationality Act.pdf | ||
| D.5 Key Personnel Roster.pdf | ||
| D.6 Past Performance Questionnaire.pdf | ||
| D.7 Subcontracting Plan Template.docx | DOCX document | |
| 36C25527Q0002.pdf |
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Text version
D.3 Organizational Conflict of Interest 36C25527Q0002
CONTRACTOR NAME:
ADDRESS:
SOLICITATION # 36C25527Q0002
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____ ________________ represents that no individuals involved with the solicitation 36C25527Q0002 for Nephrology Physician 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 Robert J. Dole VA Medical Center (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 Robert J. Dole 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
| CONTRACTOR NAME: |
| ADDRESS: |
| NAME OF CERTIFYING OFFICIALTITLE: |
| Contractor Name 2: |
| Check Box1: Off |
| Check Box2: Off |
| Date: |
File details come from the government source that posted it. Updated .