Download statement of non-conflict of interest

STATEMENT OF NON-CONFLICT OF INTEREST
PROJECT: _________________________
Purchase Order No: ______________
I HEREBY CERTIFY, IN RELATION TO THE ABOVE LISTED PROJECT:
1.
That I am the bidder (if the bidder is an individual), a partner in the bid (if the
bidder is a partnership), or an officer or employee of the bidding corporation having
authority to sign on its behalf (if the bidder is a corporation). “Bidder” shall be used
interchangeably with “person providing quote” based on whether a bid or phone quote,
respectively, is being solicited.
2.
That the bidder, or person providing an oral quote, is legally entitled to enter into
the contract with the Commonwealth of Kentucky and its agency, Eastern Kentucky
University, and is not in violation of any prohibited conflict of interest, including those
prohibited by the provisions of KRS 45A.455 or KRS 164.390.
3.
That the bidder acknowledges a certificate of insurance is on file with EKU
Facilities Services office and that it is current and will remain current for the extent of
this project.
4.
That the bidder understands and will abide by the following smoking policy: The
use of tobacco products, including smokeless tobacco products, is prohibited in all
University residence halls, academic and service buildings, athletic venues, and
designated non-smoking areas. The use of tobacco products is prohibited within twentyfive (25) feet of any such building intake duct, window or entrance or entryway,
including ramps, walkways, pathways, and any such similar means of entry, unless a
University designated tobacco use shelter is otherwise provided.
Persons who wish to use tobacco products outside of a building shall do so in a manner
that minimizes an accumulation of smoke and tobacco waste. Individuals who use
tobacco products are responsible for the proper disposal of such in designated
receptacles.
SIGNED BY: _____________________________ TITLE: _____________________
FIRM: _______________________________ TELEPHONE NO: _______________
ADDRESS: _____________________________________ DATE: _____________
CITY: _________________________ STATE: ___________ ZIP: _____________
FEDERAL I.D. NO. OR SOCIAL SECURITY NO.: __________________________