D.4 Organizational Conflict of Interest.pdf

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Q522--Radiation Oncology Physician Services NAICS 621111, PSC Q522 VAAR 873 Procedures Phased Acquisition AMENDMENT 1
Solicitation number
36C25524R0061_1
Issued by

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This document is a Contractor Conflict of Interest Certification Statement related to Solicitation Number 36C25524R0061 for Radiation Oncology Physician Services at the John Cochran VA Medical Center. The contractor certifies that no individuals involved in this solicitation have any present, planned, or past organizational conflicts of interest related to the services to be provided. The contractor may attach a statement describing any relevant facts concerning potential conflicts of interest. The document requires the contractor to provide information on any consultants or subcontractors that will provide services under the solicitation. The solicitation requires various qualifications and certifications for key personnel, including curriculum vitae, licenses, certifications, and insurance details.

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Other files

File Type Posted
36C25524R0061_1Amendment1.pdf PDF
36C25524R0061 0001.pdf PDF
D.6 Past Performance References.pdf PDF
D.5 Immigration and Nationality Act.pdf PDF
D.3 VASTLHCS ByLaws for Physicians.pdf PDF
36C25524R0061_1.docx DOCX document
D.1 Quality Assurance Surveillance Program QASP.pdf PDF
D.6 Past Performance References.pdf PDF
D.2 Contractor Rules of Behavior.pdf PDF

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Organizational Conflict of Interest

CONTRACTOR NAME:

ADDRESS:

SOLICITATION # 36C25524R0061

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] ____ ________________ represents that no individuals involved with the solicitation 36C25524R0061 for Radiation Oncology 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 John Cochran 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 John Cochran 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:

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