D.6 - Organizational Conflict of Interest.pdf
PDF 393 KB Posted
- Solicitation number
- 36C26322R0031
About this file
This document is an organizational conflict of interest certification statement template for solicitation number 36C26322R0014 for ophthalmology health technician services to be provided at the Rochester, Minnesota VA clinic. The contractor must disclose any past, present, or planned interests or conflicts relating to the services requested that could affect the contractor's objectivity or performance. Specifically, the contractor must disclose any relevant financial, contractual, organizational, or other interests involving key personnel listed in the solicitation. Alternatively, the contractor may provide an attached statement describing any such conflicts in a concise manner. The contractor must also provide similar disclosure statements for any consultants or subcontractors. The certification must be signed and dated by an authorized official of the contractor.
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Other files
| File | Type | Posted |
|---|---|---|
| D.4 - Immigration and Nationality Act requirement.pdf | ||
| S02 - 36C26322R0031.pdf | ||
| D.1 - VA Rules and Behavior.pdf | ||
| D.2 - Background Investigation Procedure and Documents.pdf | ||
| D.3 - QASP.pdf | ||
| D.5 - VA Handbook 6500.6.pdf | ||
| 36C26322R0031_1.docx | DOCX document |
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Text version
D.6 – Attachment 6 – Organizational Conflicts of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C26322R0014, Ophthalmology (Ophthalmic) Health Technician Services, for the Minneapolis VAHCS provided at the Rochester VA Clinic, 3551 Commercial Drive South West, Suite 400, Rochester, MN 55902
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] _____________________(Contractor Name) represents that the individuals listed in the Key Personnel section of the solicitation 36C26322R0014, Ophthalmology (Ophthalmic) Health Technician 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 Minneapolis 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 Minneapolis 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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