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 twenty-five (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.: __________________________

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