T2621 Appendix A - Conflict of Interest Certification 9.29.26.pdf
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- Solicitation number
- 26DPP01289
- Issued by
- New Jersey
About this file
This is a Conflict of Interest Certification form for the New Jersey Department of Environmental Protection (NJDEP) Remedial Investigation and Design Services contract (T2621). The certification document establishes the framework for declaring potential conflicts of interest by contractors, consultants, and service providers bidding on or engaged in this remedial investigation and design project. The form requires disclosure of any financial interests, business relationships, or other circumstances that could compromise the objectivity or impartiality of the contractor in performing environmental remediation and design services for the state.
The certification mandates that all parties involved in the contract must attest to the absence of conflicts of interest or disclose any existing conflicts that have been identified and mitigated through established procedures. Signatories must confirm their understanding of New Jersey's conflict of interest laws and regulations, as well as their commitment to maintaining ethical standards throughout contract performance. This documentation serves as a binding declaration of compliance and establishes accountability for all contractors and their team members involved in the NJDEP project.
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Text version
April 2026
CONFLICT OF INTEREST CERTIFICATION
T2621 - NJDEP CSRR Remedial Investigation and Design Services Bid Solicitation 26DPP01289
Site Information: Site Name Street Address Town County, New Jersey
PI#
Pursuant to the Conflict of Interest Section of the RFP for the Remedial Investigation/Design/Action Services contract T2621, I hereby affirm that my firm or any subcontractor(s):
A. ______ Had NO contractual or other business relationship with any of the persons or entities named below.
______ Had relationships with any of the persons or entities as listed and described below.
B. ______ Have done NO work on or with respect to the site.
______ Have done work on or with respect to the site as listed and described below.
C. ______ Have NOT been, NOR are currently named, a Potentially Responsible Party (PRP), at this site.
______ ARE, or WERE, named a PRP at this site as described below.
LIST OF POTENTIALLY RESPONSIBLE PARTIES:
The Contractor must disclose any contractual or other business relationship occurring during the preceding five years between the Contractor and any subcontractor of the Contractor and any person or entity who is or may be responsible for the cleanup costs of this site. The Contractor and any subcontractor shall disclose any work that they have previously performed at the site.
Below, or attached, please provide details of any relationship with any of the PRP’s, include the type of work performed, approximate value of work performed, and when the work was performed.
DETAILS:
Date Signature
Type or Print Name
Name of Proprietorship, Partnership, or Corporation Submitting Form
APPENDIX A
| CONFLICT OF INTEREST CERTIFICATION |
| LIST OF POTENTIALLY RESPONSIBLE PARTIES: |
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