Gettysburg College - Conflict of Interest Disclosure Form
FOR GRANT APPLICATIONS TO THE FEDERAL GOVERNMENT
If you are applying for a Federal grant which would be administered by the College, complete and return this form
to Foundation, Government, and Faculty Grants (Laura Runyan – lrunyan@gettysburg.edu
)
Grant Period
I. C
onflict of Interest Disclosure
1. I have read and agree to be bound by the College’s Conflict of Interest Policy For Faculty and Academi
c
Staff A
pplying for Gettysburg College Administered Federal Grants (Refer to attachment), which applies to
all members of Gettysburg’s faculty or academic staff who are involved in grants and contracts sponsor
ed
b
y the Federal government. Federal regulations require faculty and staff to renew this certification
annually or as new reportable significant financial interests are obtained.
2. D
o you or a member of your family have a "significant financial interest" as that term is defined in
the
Federal Grant COI?
No, I/we do not. Yes, I/we do. Describe the nature of this conflict with this form.
I
I. Debarment and Suspension Certification
1. The prospective primary participant certifies to the best of its knowledge and belief, that it and it
s
principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from a covered transaction by any Federal department or agency; (b) Have not within
a three-year period preceding this proposal been convicted of or had a civil judgment rendered again
st
them
for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, o
r
performing a public (Federal, State or local) transaction or contract under a public transaction; violation of
Fed
eral or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification o
r
d
estruction of records, making false statements, or receiving stolen property; (c) Are not pres
ently
in
dicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or lo
cal)
with c
ommission of any of the offenses enumerated in paragraph (1)(b) of this certification; and (d) Hav
e
not within a three-year period preceding this application/proposal had one or more public transactions
(Fed
eral, State or local) terminated for cause or default.
2. Where
the prospective primary participant is unable to certify to any of the statements in thi
s
cert
ification, such prospective participant shall include an explanation with this proposal.
Certification
I certify that the foregoing and proposal application information is true, complete, and accurate to the best of my
knowledge; that I understand that any false, fictitious, or fraudulent statements may subject me to criminal, civil,
or administrative penalties; and that I agree to accept responsibility for the scientific conduct of the project and to
provide the required progress reports if a grant is awarded as a result of the application.
Si
gnature
click to sign
signature
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