ESBD_559828_1789660221940_RFO 300-26-07176 Exhibit D - Conflict of Interest Disclosure.pdf
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- Solicitation number
- RFO-300-26-07176
- Issued by
- Texas
About this file
This is a Conflict of Interest Disclosure and Certification form (Exhibit D) for RFO No. 300-26-07176 issued by the State of Texas for Cable Television Services, including pay-per-view services. The form is mandatory for all respondents, and failure to complete, sign, and submit it with the proposal will result in disqualification. Respondents must certify that they have read and understand all conflict of interest provisions, contract certifications, and conflict of interest statutes referenced in the RFP, specifically those outlined in Part B, Sections 14, 16, 21, and 54. Respondents must also declare whether they have any actual or potential conflicts of interest or confirm that no conflicts exist.
Respondents must certify compliance with three specific Texas Government Code sections: Section 669.003 (restrictions on contracting with executive heads of state agencies), Section 572.069 (prohibitions on employment of state officers and employees who participated in procurement), and Section 2252.901 (contracts with former or retired agency employees). If any of these statutes apply to the respondent, the respondent must disclose the name of the former executive or employee, the state agency involved, the separation date, and the employment date with the respondent. Respondents are under a continuing duty to supplement their disclosures if circumstances change or additional information is obtained after proposal submission, and must provide updated information as soon as reasonably possible upon learning of any changes.
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Text version
RFO No. 300-26-07176
EXHIBIT D
CONFLICT OF INTEREST
Disclosure
FAILURE TO COMPLETE, SIGN AND SUBMIT THIS EXECUTION OF PROPOSAL
FORM WITH RESPONDENT’S PROPOSAL MAY RESULT IN DISQUALIFICATION
RESPONDENT CONFLICT OF INTEREST DISCLOSURE AND CERTIFICATION
By signing this Conflict of Interest Disclosure and Certification, Respondent certifies and affirms the following:
1) Respondent has read and understands the various conflict of interests contract provisions, contract certifications, and conflict of interest statutes cited in the RFP, including, but not limited to, those contained in RFP Part B, Sections 14 (Prohibited Bids and Contracts), 16 (Gift to Public Servant), 21 (Conflicts of Interest; Disclosure of Conflicts; Disclosure of Interested Parties), and 54 (Compliance with Applicable Laws).
2) Except as otherwise disclosed in this Conflict of Interest Disclosure and Certification, Respondent, Respondents’ employees, and Respondents’ subcontractors do not have, nor shall they knowingly acquire, any interest that would create a conflict of interest, create the appearance of a conflict of interest, or be adverse to or conflict in any manner with the performance of Respondent’s obligations under any contract that may be awarded as a result of this RFP.
3) Complete only one the following check boxes as applicable:
Respondent discloses the following information that may present an actual or potential conflict of interest:
Respondent does not have any actual or potential conflicts of interest to disclose.
4) Respondent is compliant, and will remain in compliance during the term of any contract that may be awarded as the result of this RFP, with the following Sections of the Texas Government Code: Section 669.003 (Restriction on Contracting with Executive Head of State Agency); Section 572.069 (Prohibiting employment of state officers and employees who participated in the procurement of services); and Section 2252.901 (Contracts with Former or Retired Agency Employees). If any of these statutes apply, the Respondent shall complete the following information in order for its proposal to be evaluated:
Name of Former Executive or Employee: ____________________________________________________
Name of State Agency: ____________________________________________________
Date of separation from State Agency: ____________________________________________________
Date of employment with Respondent: ____________________________________________________
5) If the circumstances of the disclosures certified by Respondent change or additional information is obtained subsequent to the submission of Proposals, Respondent agrees that it is under a continuing duty to supplement its response under this provision, and Respondent shall submit updated information as soon as reasonably possible upon learning of any change to information contained in this disclosure and certification.
Signature - Authorized Bidder Representative
Printed Name Date
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