D.5 Organizational Conflict of Interest

D.5 Organizational Conflict of Interest
36C25526R066

CONTRACTOR NAME:

ADDRESS:

SOLICITATION # 36C25526R066

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

the solicitation 36C25526R066 for Referral Lab Services in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Veterans Integrated Services Network (VISN) 15 Veterans Administration under the referenced solicitation.
None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Veterans Integrated Services Network (VISN) 15 Veterans Administration under the referenced solicitation. OR
[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.

NAME OF CERTIFYING OFFICIAL/TITLE

SIGNATURE

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DATE