D.6 Organizational Conflict of Interest.pdf
PDF 140 KB Posted
- Attached to
- Q515--Blood Bank Physician Services - MPLS
- Solicitation number
- 36C26323R0057
About this file
This document is an organizational conflict of interest certification statement for solicitation number 36C26323R0057 for blood bank physician services at the Minneapolis VA Health Care System. The contractor must disclose any past, present, or currently planned interests or conflicts of interest for its key personnel, consultants, and subcontractors related to providing the services. The contractor must also describe any actions taken to avoid or mitigate potential organizational conflicts of interest. The certification must be signed and dated by an authorized official of the contractor.
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Text version
D.6 – Attachment 6 – Organizational Conflicts of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C263R0057, Blood Bank Physician Services, Minneapolis VAHCS
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] _____________________(Contractor Name) represents that the individuals listed in the Key Personnel section of the solicitation 36C26323R0057, Blood Bank 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 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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