Current or Former Executive Branch or Judicial Branch Employees
Various statutes, regulations, and rules govern the post-government employment activities of former military personnel and federal government employees. Violations of these statutes, regulations, and rules may lead to the imposition of severe penalties on Vencore and the former government employees. You are required to furnish the following information which will be used by Vencore to determine whether it is permissible for us to employ you or acquire your services and, if permissible, to specify the particular duties you may perform on behalf of Vencore If any of your responses may be classified, do not answer the question and inform Vencore Human Resources or Procurement representative. Further information may be required through authorized channels.
Complete a separate form for each applicable military branch or government agency.
1. / Name:
Military Personnel /
Government Service Personnel
2. / Level: / Flag/General OfficerOther:______/ Level: / ES – Executive Schedule
SES – Senior Executive Service
GS – General Schedule
3. / Branch: / Army
Navy
Air Force
Marines
Coast Guard / Agency: / Department of Commerce
Department of Defense (DoD)
Department of Energy
Department of Homeland Security
Department of State
Department of Transportation
Department of the Treasury
Department of Veterans Affairs
Environmental Protection Agency
NASA
National Reconnaissance Office
State & Local Government
US Postal Service
White House/Executive Office of the President
Other:______
4. / Former position/title:
5. / Date/projected date of your separation from service with the US government:
6. / Dates of service: / From: / To:
7. / Former role(s):
Procurement official with regard to any procurement involving Vencore with a value over $10 million, i.e., contracting officer; source selection authority; member of source selection board; chief of financial or technical evaluation team; or program or deputy program manager.
Decision maker with regard to any procurement involving Vencore with a value over $10 million, i.e., contract, subcontract, modification or task order award; establish or approve overhead or other rates; approve contract payment; or payment or settlement of a claim over $10 million.
Personal and substantial involvement with a particular matter involving Vencore
Official responsibility (directly or through subordinates) over a particular matter involving Vencore
Other official duties related to Vencore Please specify:______
______
*DoD official who participated personally and substantially in an acquisition with a value exceeding $10 million and who served in an ES position, in the SES, or in a general or flag officer position at pay grade O7 or above.
*DoD official who served as a program or deputy program manager, procuring contracting officer, administrative contracting officer, source selection authority, member of source selection evaluation board, or chief of a financial or technical evaluation team for an acquisition with a value exceeding $10 million.
None of the above.
*Applies to any acquisition with a value exceeding $10 million, not just those involving Vencore Please provide the written opinion from the agency ethics office regarding the applicability of post-government employment restrictions to activities that you are expected to perform for Vencore
8. / Restriction (to be completed by the applicant):
Communication with any government employee serving in an Executive Schedule position in any agency
Communication with any government employee about a particular Vencore matter
Communication with employee’s former agency/department about any matter
Employment by the Vencore entity responsible for the contract for which the employee was involved as a procurement official. Product/contract: ______
None
9. / If not otherwise set forth above, is there any position or assignment you would be uncomfortable in performing on account of possible conflicts of interest or impropriety? Yes No. If Yes, please explain:
10. / Have you at any time been debarred or suspended from participation in government contracting or have you been notified that such action is pending? Yes No
11. / Have you been convicted of or pleaded guilty to government contract or procurement fraud? Yes No
12. / Comments:
I hereby certify that the above statements are true and accurately depict my former military/government service.
Signature: / Date:
Vencore Use
1. / Legal review and approval are required before proceeding with the offer or services acquisition process if the applicant:
a. / Checked any former role (line 7), or
b. / Answered YES at line 9 (possible conflict of interest or impropriety), line 10 (suspension or debarment), or
line 11 (contract or procurement fraud).
2. / To be completed by Legal: Based on the information provided, Vencore may consider employing the individual or acquiring his or her services because there is no conflict of interest: Yes No
a. / If NO, specify issues and concerns:
b. / If YES, indicate restriction, if any:
Signature: / Date:
Page 2 of 2-523-1 (August 10, 2009)
Page 2 of 2-523-1 (August 10, 2009)