D.6 Attachment 6 - Organizational Conflict of Interest.pdf
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- Solicitation number
- 36C26324R0117
About this file
This document is a Conflict of Interest Certification Statement from a contractor responding to Solicitation #36C26324R0117 for Urology Physician Services for the VA Healthcare System in Des Moines, Iowa. The contractor certifies that the key personnel listed in the solicitation have no present, planned, or past conflicts of interest related to the services to be provided. Alternatively, the contractor may attach a statement describing any relevant facts concerning conflicts of interest. The solicitation is for a contract period of performance from 10/1/2024 to 3/31/2025, issued by the Department of Veterans Affairs, Veterans Health Administration, Veterans Integrated Service Network 23.
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D.6 – Attachment 6 – Organizational Conflicts of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C26324R0117, Urology Physician Services, VA-CIHCS 3600 30th Street Des Moines, IA 50310
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] _____________________(Contractor Name) represents that the individuals listed in the Key Personnel section of the solicitation 36C26324R0117, Urology Physician 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 Health Care System 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 Health Care System 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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