Preparer Note: This form is to be completed by the Named Individual and returned to the Subcontract Administrator with his/her proposal.

Named Individual-Conflict of Interest Disclosure

Name:
Address:(Street, City, State
ZIP Code, Country)
Phone Number:
Please complete the following information concerning current or prior relationships with LANS or LANS employees.
  1. Disclose all current and/or prior subcontracting relationships with LANS (either directly or as a lower-tier subcontractor ) including the current and/or prior subcontracting relationships of Near Relatives (Near Relatives are defined as a spouse, domestic partner, parent, child, sibling, step relative, or in-law). List below or indicate “NA” if none.

  1. Describe any relationship (including family and others) with current LANS employees. List below or indicate “NA” if none.

  1. Describe any relationship (including family and others) with current DOE/NNSA employees. List below or indicate “NA” if none.

  1. Are you a former LANS employee (or prior to 2006, University of California employee)?

Yes No
If yes, please list your last position, date your employment with LANS/UC ended, and annual salary.
  1. Disclose any financial, business, or personal relationships with any member of the LANS Board of Governors (BOG), BOG Committees, or LANS affiliated organizations (i.e., Bechtel National, Inc., University of California, The Babcock and Wilcox Company, and URS Corporation).List below or indicate “NA” if none.

  1. Describe any business, employment, or personal relationships with a LANSemployeenot previously discussed. List below or indicate “NA” if none.

Certification
I certify that I have answered all questions accurately and completely. To the best of my knowledge and belief, I have disclosed all facts that could cause a conflict, or an appearance of a conflict, between my responsibilities as a LANS service provider and my personal and/or business interests and the personal and/or business interests of my Near Relatives. I further assert that I am not currently employed by LANS, LLC.
Signature of Named Individual / Printed Name / Date

Rev.1 Page 1 of 2 NIRT Form 3

Date: 07/09/13