VENDOR Disclosure Form Japan.doc

BIDDER'S PROCUREMENT RELATIONSHIP DISCLOSURE

PRIVATE

Japan Destination Marketing and Public Relations Services

Bid: 2015-MOTT-01 As a bidder on this Commonwealth of Massachusetts procurement, any business or personal association with any member of the Procurement Management Team within the last 24 months must be disclosed.

YOUR NAME & TITLE

COMPANY NAME

PROCUREMENT MANAGEMENT TEAM:

Lisa Simmons, Massachusetts Office of Travel & Tourism (MOTT) Lesley White, Massachusetts Office of Travel & Tourism Maria Speridakos, Massachusetts Office of Travel & Tourism Complete and sign section A or section B below.

A: NO ASSOCIATIONS

On behalf of ________________________________, I hereby certify that this entity and all staff for this project have not been associated with, nor had any monetary, familiar, or other relationship with, any of the above listed members of the Procurement Management Team or with other MOTT staff within 24 months of the date of this signing.

SIGNATURE

DATE

B: ASSOCIATIONS TO BE DISCLOSED

On behalf of ________________________________, I hereby certify that this entity and staff for this project have been associated with, or had a monetary, familiar, or other relationship with, one or more of the above listed members of the Procurement Management Team or with other MOTT staff within 24 months of the date of this signing. Details of the relationships are described below.

SIGNATURE

DATE

Description of relationships: [USE ADDITIONAL PAGES IF NECESSARY]