Government Contract Conflict of Interest Disclosure Form
Personal Information
Full Name
Position/Title
Department/Agency
Email Address
Date
Disclosure of Potential Conflicts
Do you, your spouse, or immediate family have any financial interest in this contract?
Yes
No
If yes, please describe:
Have you or your immediate family received any gifts, favors, or compensation from any entity participating in this contract?
Yes
No
If yes, please describe:
Are you currently or have you been employed by, or held a consulting position with, any company bidding for this contract?
Yes
No
If yes, please describe:
Additional Comments or Disclosures
Certification
I certify that the above information is true and complete to the best of my knowledge.