Conflict of Interestcertification Form

Conflict of Interestcertification Form

Conflict of InterestCertification Form

For HCC Vendors

Transaction Reference: ______

Vendor Name: ______

Street Address: ______

City: ______State: ______Zip Code: ______

With respect to the referenced transaction the above named vendor has been recommended for non-competitive contract award pursuant to Section 5.3.5 (Sole Source) of the Houston Community College Procurement Procedures Manual. (Note: This certification is not required for contracts or purchase orders under $2,500.)

The vendor certifies that it is in compliance with all applicable federal, state and local laws, ordinances, rules and regulations with respect to ethics and conflict of interest, including but not limited to:

Texas Education Code

Texas Government Code

Houston Community College Policies and Procedures

Procurement Operations Manual

In compliance with the aforementioned, the below signed person hereby certifies that, with respect to the procurement referenced above, except as may be disclosed below at the bottom of this page:

No employee1 or Trustee of Houston Community College having direct or indirect participation2 in the above referenced transaction, nor a relative3 of said HCC employee1:

  • Is an officer, director or employee of any person, business or organization4 involved in the procurement5;
  • Is negotiating or has an arrangement concerning prospective employment with any person, business or organization4 involved in the procurement5; or
  • Has a controlling financial interest6 in any person, business or organization4 involved in the procurement5.

No employee1 or Trustee of Houston Community College having direct or indirect participation2 in the above referenced transaction, nor an immediate family member3 of said HCC employee1:

  • Has received a “gift”8or series of “gifts”8 with a total value in excess of $100 during the preceding twelve months from any person, business or organization4 involved in the procurement5; or
  • Has received professional fees, commissions, honorariums9 or other compensation during the preceding twelve months from any business or organization4 involved in the procurement5.

No employee1 or Trustee of Houston Community College having direct or indirect participation2 in the above-referenced transaction has been employed by, or had a controlling financial interest6 in, any person, business or organization4 involved in the procurement5 for a period of two years prior to this certification.

List any exceptions or disclosures here (attach additional page if necessary):

______

______

______

Conflict of Interest Certification Form for HCC Vendors

VERIFICATION: I declare that this Conflict of Interest Certification Form has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of any conflicts the above named vendor may have with respect to the above referenced procurement. If at any time prior to the award of the contract by HCC I discover an actual or potential conflict of interest not previously disclosed, I will notify the HCC Executive Director & Chief Procurement Officer in writing within three (3) business days of discovering the conflict. I further represent that I am a sole proprietor, partner, officer or other person duly authorized to execute this certificate on behalf of the above named vendor.

I further declare that with regards to the transaction referenced above, that I have not been in nor will I engage in any communications with members of the HCC Board of Trustees or staff in reference to this transaction, and will ensure that any request for clarification will promptly be forwarded to the Procurement Operations Department. I fully understand that any violation, on my part, with the Blackout Period (as further defined in Section 1.7.10 and 3.3 of the Procurement Operations Manual) may result in the cancellation of the referenced transaction, disbarment, disqualification from future procurement solicitations and prosecution in accordance with the Laws of the State of Texas.

By: ______Title: ______

(Signature)

Name: ______Date: ______

(Printed)

DEFINITIONS

  1. Employee of Houston Community College means a Trustee or other public officer, any individual drawing a salary, and any non-compensated individual performing services for the HCC, other than for any HCC’s Voluntary Services Department. Directors and employees of the Jackson Memorial Foundation are excluded from this definition.
  2. Direct or Indirect Participation means involvement through decision, approval, disapproval, recommendation, preparation of any part of a purchase request, influencing the content of any specification or procurement standard, rendering of advice, investigation, auditing, or in any other advisory capacity.
  3. Relative will be defined in two parts in accordance with the provisions of Chapter 573 of the Texas Government Code related to “Nepotism.”
  4. Consanguinity within the third degree:“An individual’s relatives within the third degree by consanguinity (computed by civil law method)” are:
  5. first degree: the individual’s parent or child
  6. second degree: the individual’s brother, sister, grandparent or grandchild
  7. third degree: the individual’s great-grandparent, great-grandchild, aunt who is the sister of a parent, uncle who is the brother of a parent, nephew who is the child of a brother or sister, or niece who is a child of a brother or sister.
  8. Affinity within the second degree:“Affinity” refers to a relationship created by marriage. Two individuals are related by affinity if they are married to each other or if the spouse of one of the individuals is a blood relative of the other.An individual’s relatives within the second degree by affinity are:
  9. anyone related by consanguinity to the individual’s spouse within the first or second degrees; or
  10. the spouse of anyone related to the individual by consanguinity within the first or second degrees.
  11. Person, business or organization includes, but is not limited to, any prime contractor, any tier subcontractor, vendor or lobbyist.
  12. Involved in the procurement means the submission of a bid or proposal; or being recommended for the award of a non-competitive procurement.
  13. Controlling Financial Interest means the ownership, directly or indirectly, of ten (10) percent or more of the outstanding capital stock in any corporation, or an ownership interest, direct or indirect, of ten (10) percent or more in a firm, partnership, or other business entity.
  14. Immediate Family Member means spouse, domestic partner, parents and children of the employee.
  15. Gift means the transfer of anything of economic value, whether in the form of money, service, loan, travel, entertainment, hospitality, item or promise, or in any other form, without adequate and lawful consideration. The term “gift” shall include any professional samples which were not used solely by the Houston Community College System in conducting its official business.
  16. Honorarium means a payment of money or anything of value, directly or indirectly, to an employee, or to any other person on his or her behalf, as consideration for:
  17. A speech, address, oration, or other oral presentation of the employee, regardless of whether presented in person, recorded, or broadcast over the media; or
  18. A writing by the employee, other than a book, which has been or is intended to be published.

Created: February 24, 20111

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