06_Attachment_5_Certification_Regarding_Conflict_of_Interest.pdf

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AUTOMATION PROGRAM-ITALY
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SPE600-16-R-0225
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SOLICITATION NUMBER SPE600-16-R-0225

TAX-FREE FUEL CARD – ITALY

ATTACHMENT 5

Certification Regarding Conflict of Interest

The Offeror is required to certify performance of the work will not create any conflicts of interest or disclose any actual or potential conflicts of interest by completing and signing one of the following statements:

The Offeror hereby certifies that to the best of its knowledge and belief, performance of the services described in the Scope of Work will not create any conflicts of interest for the Proposer, any affiliates, any proposed Sub-consultants or key personnel of any of these organizations.

DATE: _________________________________________________________________________

AUTHORIZED SIGNATURE: ________________________________________________________

TITLE: _________________________________________________________________________

OFFEROR/COMPANY NAME: _____________________________________________________

OR

The Offeror hereby discloses the following circumstances that could give rise to a conflict of interest for the Offeror, any affiliates, any proposed Sub-consultants or key personnel of any of these organizations.

Name of Individual/Company to which potential conflict of interest might apply:

Nature of potential conflict of interest _______________________________________________

Proposed Remedy ________________________________________________________________

DATE: _________________________________________________________________________

AUTHORIZED SIGNATURE: ________________________________________________________

TITLE: _________________________________________________________________________

OFFEROR/COMPANY NAME: _____________________________________________________

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