No Conflict of Interest_Certification Form (Purchasing 8-25).pdf
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- Attached to
- Portable Screener & RC Tracked Skid Steer
- Solicitation number
- 2136583
- Issued by
- Richmond County, New York
About this file
This is a No Conflict of Interest Certification Form issued by the New York State Department of Transportation (NYSDOT) Administrative Services Division, Purchasing, for vendors responding to solicitations for state contracts. The form requires offerers—whether contractors, subcontractors, or consultants—to certify that performance of services will not create conflicts of interest or detrimental effects on state projects. Vendors must attest that contract fulfillment complies with existing state agreements, does not compromise ability to perform current state obligations, and will not result in diversion of resources between state projects. The certification applies to the solicitation for a Portable Screener and RC Tracked Skid Steer to be utilized by NYSDOT Region 6, with interested entities instructed to contact Purch-Assist@dot.ny.gov to request bid package materials and be placed on the bidder's list.
The form requires authorized executive or legal representatives to sign and date the certification, confirming understanding of and agreement to comply with New York State conflict of interest procedures. Vendors must declare that no former state officers or employees now working for the firm, and no former firm employees now employed by the state, have participated in contract procurement administration in violation of Section 73(8)(a) of the State Ethics Law. Additionally, vendors must certify they have not offered gifts of any form to state employees, members, or directors under circumstances that could influence official duties or reward official actions. The state reserves the right to terminate contracts for cause if real or potential conflicts of interest cannot be cured, acknowledging that conflicts may arise from existing or new vendor relationships requiring state review and determination.
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Text version
(10/16)
Administrative Services Division - Purchasing
NEW YORK STATE DEPARTMENT of TRANSPORTATION
VENDOR ASSURANCE of NO CONFLICT of INTEREST or
DETRIMENTAL EFFECT — OFFERER CERTIFICATION FORM
The firm offering to provide services pursuant to this solicitation, as a contractor, subcontractor or consultant, attests that its performance of the services outlined in this solicitation does not and will not create a conflict of interest with nor position the firm to breach any other contract currently in force with the State of New York.
Furthermore, the firm attests that it will not act in any manner that is detrimental to any State project on which the firm is rendering services. Specifically, the firm attests that:
1. The fulfillment of obligations by the firm, as proposed in the response, does not violate any existing contracts or agreements between the firm and the State;
2. The fulfillment of obligations by the firm, as proposed in the response, does not and will not create any conflict of interest, or perception thereof, with any current role or responsibility that the firm has with regard to any existing contracts or agreements between the firm and the State;
3. The fulfillment of obligations by the firm, as proposed in the response, does not and will not compromise the firm’s ability to carry out its obligations under any existing contracts between the firm and the State;
4. The fulfillment of any other contractual obligations that the firm has with the State will not affect or influence its ability to perform under any contract with the State resulting from this solicitation;
5. During the negotiation and execution of any contract resulting from this solicitation, the firm will not knowingly take any action or make any decision which creates a potential for conflict of interest or might cause a detrimental impact to the State as a whole including, but not limited to, any action or decision to divert resources from one State project to another;
6. In fulfilling obligations under each of its State contracts, including any contract which results from this solicitation, the firm will act in accordance with the terms of each of its State contracts and will not knowingly take any action or make any decision which might cause a detrimental impact to the State as a whole including, but not limited to, any action or decision to divert resources from one State project to another;
7. No former officer or employee of the State who is now employed by the firm, nor any former officer or employee of the firm who is now employed by the State, has played a role with regard to the administration of this contract procurement in a manner that may violate section 73(8)(a) of the State Ethics Law; and
8. The firm has not and shall not offer to any employee, member or director of the State any gift, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any other form, under circumstances in which it could reasonably be inferred that the gift was intended to influence said employee, member or director, or could reasonably be expected to influence said employee, member or director, in the performance of the official duty of said employee, member or director or was intended as a reward for any official action on the part of said employee, member or director.
Firms responding to this solicitation should note that the State recognizes that conflicts may occur in the future because a firm may have existing or new relationships. The State will review the nature of any such new relationship and reserves the right to terminate the contract for cause if, in its judgment, a real or potential conflict of interest cannot be cured.
Offerer affirms this Day of , 20 that he/she understands and agrees to comply with the New York State procedures relative to Conflicts of Interest – (entity shall seek written affirmations as to the offerer’s understanding and agreement to comply).
Business Entity Name and Address:
By (Signature) ________________________________________ Print Name and Title
This form must be signed by an authorized executive or legal representative
Contract/Procurement
| Offerer affirms this: |
| Day of: |
| 20: |
| Text1: |
| Text2: |
| Text3: |
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