Consultant Disclosure Statement

CONSULTANT

DISCLOSURE STATEMENT

DECLARATION

__________________________________________________________

(Name) declares that they have no direct financial or other

interests in the outcome of the Department of Veterans Affairs

project

for

the

________________________________________

(Title of project) at VAMC, ________________________________

(Location of project), nor will they necessarily derive any

benefit

payment

from

contracts

resulting

from

the

environmental analysis being performed.

The undersigned warrants that he (she) is an official

representative of __________________________________________

(Name of company) and authorized to endorse compliance with

this Declaration.

_________________________________

________________________

Name

Date

10/98