Non-Disclosure_Form.doc

ATTACHMENT J.5

CONFLICT OF INTEREST AND NON-DISCLOSURE AGREEMENT

1. I, the undersigned, certify that I will not discuss or reveal any information pertaining to TOPR No. _____________ (insert title of TOPR ____________) to anyone who has not been approved by the Contracting Officer (CO).

2. I further agree that at any time I discover that I have an interest in or connection with, a company submitting a proposal, I shall promptly report, in writing, the fact of my interest or connection, and the nature of it, to the CO. I recognize that a reportable interest or connection includes, but is not limited to, the following:

a. Ownership of a company’s securities by me or my spouse.

b. A close family relationship to an official of a company submitting a proposal or participating as a subcontractor.

c. Any other interest in or connection with a company that might subject Federal Highway Administration to criticism on the basis that such interest or connection would impair my objectivity in participating in the proposal evaluation proceedings including conduct of cost/price analysis.

3. I further agree that, upon completion of my review of subject proposals, I will return all copies of the proposals (including any abstracts thereof) and any related documentation to CO or their duly authorized Government representative.

4. In addition, I fully realize that any breach by me of my obligation to safeguard and not disclose to unauthorized persons any information made available to me concerning the subject RFP, may result in appropriate disciplinary action, provided for by law or regulation, being taken against me by duly constituted authority.

5. To the extent that my participation in this procurement requires access to proprietary, business confidential, or financial data of other companies, and as long as such data remains proprietary or confidential, I will protect such data from unauthorized use and disclosure and agree not to use it to compete against such companies.

Any questions on this document shall be immediately addressed to (insert name of Contracting office ______________________ at (202) 366-XXXX.

Print Name: (Insert Name of Chair) Print Organization Name: US DOT FHWA (insert routing code _________________) Signature:

Date: (insert date)