D.5 Contractor Conflict of Interest Certification Statement.docx
DOCX document 27 KB Posted
- Attached to
- Q522--Tele-radiology Services - VA Atlanta HCS
- Solicitation number
- 36C24725Q0002
About this file
This is a Contractor Conflict of Interest Certification Statement template for solicitation #36C24725Q0002 for Teleradiology Services at the Atlanta VA Healthcare System.
The document requires contractors to certify either that no individuals involved in the solicitation have any present, past, or planned interests (financial, contractual, organizational) related to the services, or alternatively, to provide a detailed statement describing any relevant conflicts of interest. If conflicts exist, contractors must explain how their organizational/management systems would avoid or mitigate potential conflicts. The certification applies to both the primary contractor and any subcontractors or consultants who will provide services under the solicitation. The document must be signed and dated by a certifying official from the contracting organization.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24725Q0002 Solicitation.docx | DOCX document | |
| D.2 VA Tele-Radiology Handbook.docx | DOCX document | |
| D.3 Limitation on Subcontracting Clause.docx | DOCX document | |
| D.6 Contractor Certification Immigration and Nationality Act.docx | DOCX document | |
| D.1 Tele Radiology QASP.docx | DOCX document | |
| D.4 MOU-ISA.docx | DOCX document |
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Text version
36C24725Q0002 D.5 Contractor Conflict of Interest Certification Statement
Organizational Conflict of Interest
[CONTRACTOR NAME] _______________________________
[ADDRESS] __________________________________________
SOLICITATION # 36C24725Q0002
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that no individuals involved with the solicitation # 36C24725Q0002 for Teleradiology 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 Atlanta VA HCS 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 Joseph Maxwell Cleland Atlanta VA Medical Center/VA Atlanta Healthcare System 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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