UNIVERSITY OF CALIFORNIAUC PROCUREMENT SERVICESREPORT AND CERTIFICATION OF PROPOSED TRANSACTION INVOLVING A POTENTIAL CONFLICT OF INTERESTEach individual or company offering to provide goods or services to the University must complete this form if that individual or company meets any of the below criteria:A. Are or owned by a current UC employee of any locationB. Are or owned by a former UC employee of any location, who has been separated for less than two (2) years (retired, dismissed, separated, or formerly employed)C. Are or owned by a current UC employee of any location, who owns or controls 10% or greater interest in a business that will provide goods or services to the UniversityD. Are or owned by a near relative of a current UC employee of any location (spouse, domestic partner or relative of the domestic partner, child, parent, brother, sister, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law of a University employee, and step-relatives in the same relationship)E. Are or owned by a near relative of a current UC employee of any location, when that near relative owns or controls 10% or greater interest in a business that will provide goods or services to the UniversityF. Any UC employee will be paid by the proposed supplier for the proposed transaction.General Transaction InformationFull Legal Name of proposed supplier: * Which of the above listed criteria (A-F) best meets your situation? (Select all that apply) * A. Are or owned by a current UC employee of any location B. Are or owned by a former UC employee of any location, separated less than 2 years C. Current UC employee owning/controlling 10% or greater interest in business D. Near relative of a current UC employee of any location E. Near relative owning/controlling 10% or greater interest in business F. Any UC employee will be paid by proposed supplier for this transactionName of UC Employee: * Please indicate which of the following is applicable:Option 1: current UC employeeDepartment where employed Job Title UC location where employed Does your position include teaching or research responsibilities? YES NODescription of UC employment job duties: Option 2: former UC employee, who has been separated for less than two (2) years (retired, dismissed, separated, or formerly employed)UC location where employed Department where employed Job Title Separation Date: Option 3: near relative of a current UC employee (spouse, child, parent, brother, sister, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, sister-in-law, and step relatives and domestic partners in the same relationship)Name of relative (UC employee) Relationship to current UC employee Relative's UC Campus and Department Does your near relative UC employee's position include teaching or research responsibilities? YES NOConflict QuestionnaireCurrent and former employees ONLY: Do you/Did engage in any of the negotiations, transactions, planning, arrangements, or any part of the decision making process relevant to the transaction while employed by any University location? YES NOCurrent and former employees ONLY: Has any/Did any of your University time, University material, University equipment, or was University facilities used or will be used in connection with the proposed transaction? YES NORelatives of UC employees ONLY: Does your near relative have any past, current, or future responsibility for, involvement in, or direct or indirect influence on any of the negotiations, transactions, planning, arrangements, or any part of the decision making process relevant to the proposed transaction? YES NOFor former employees ONLY: did you hold a policy-making position in the same general subject area as the proposed transaction, during the last twelve (12) months of UC employment? YES NOIf you answered YES to any of the above questions, please explain. Attach additional sheet if needed: Provide complete details regarding any shared time, facilities, or decision-making involvement.Goods & Services Description & CertificationDescribe the goods and/or services: * Have the goods and/or services already been provided to the UC? * YES NOAre these goods and/or services available in the commercial market by other providers? * YES NOSignature of UC employee, former UC employee, or near relative of current UC employee * I certify that the above information is true.Date: * Generate Fillable PDF Form UC Department Certification ONLYAre these goods and/or services available from the University's own facilities? YES NOHow did your department learn of this provider? Department Head Name Signature Date UC LOCATION PROCUREMENT ONLYHas this supplier gone through the conflict of interest process before (check the COI database)? YES NOIf Yes, what was the determination? Manager Role: Procurement Manager Material ManagerDate Determination: Approves Denies Check here if the "UC Justification For Proposed Transaction Involving a Potential Conflict of Interest" is attachedRev. 1-2020