D.4 CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT.docx

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Attached to
Mobile Positron Emission Tomography/Computerized Tomography (PET/CT) Services for Charles George (Asheville) VAMC, Hampton VAMC, and Salem VAMC
Solicitation number
36C24624R0024
Issued by

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This document contains a conflict of interest certification statement for a solicitation seeking mobile positron emission tomography/computerized tomography (PET/CT) services. The contractor named in the solicitation must certify that its key personnel listed have no present, planned, or past financial, contractual, organizational, or other conflicts of interest relating to providing the solicitation's mobile PET/CT services to three Department of Veterans Affairs medical centers. The solicitation number is 36C24624R0024 and seeks these services for the Charles George, Hampton, and Salem VAMCs under a base year contract from April 1, 2024 to March 31, 2025 with four optional one-year extensions. The contractor must provide all labor, equipment including a mobile trailer/unit, specialized staff, training, supplies, and necessary drugs to perform the PET/CT services according to the performance work statement for the period of performance.

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36C24624R0024

D.4 CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation 36C24624R0024 for Mobile PET CT services 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 VA Medical Centers 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 VA Medical Centers 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 proposal 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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