HomeMy WebLinkAboutConflict of Interest Certificate06/29/06 10:08 FAX 904 630 1182
PROCUREMENT & SUPPLY L1008/025
CONFLICT OF INTEREST CERTIFICATE
SECTION 00320
BID # SC-0511-06
Bidder trust execute either Section I or Section II hereunder relative to Florida. Statute 112.3 13(12). Failure to execute either section may result in
rejection of this bid proposal_
SECTION I
I hereby certify that no official or employee of the City or it's independent agencies requiring thc goods or services described in these specifications
has a material financial interest in this company_
Signature Company Name
Name of Official (type or print) Business Address
City, State, Zip Cade
SECTION II
1 hereby certify that the following named City otfiicial(s) and/or ertuployec(s) having material financial interest(s) (in excess of $%) in this company
have filed Conflict of' Interest Statements with the Supervisor of Elections, 105 East Monroe Street, Jacksonville, Duval County Florida, prior to bid
opening.
Name
Title of Position
Date of Filing
gignature
Name of Official (type or print)
Company Name
Business Address
City, State, Zip Code
PUBLIC OFFICIAL DISCLOSURE
Section 126.112 of the purchasing Code Requires that a public official who has a financial interest in a bid or contract make a disclosure at thc time
that the bid or contract is submitted nr at the time that the public official acquires a financial interest in the bid or contract. Please provide disclosure,
if applicable, with bid_
Public Official
Position Held
Position or Relationship with Bidder
FOKM GA- I05_ revised 611998