Department of Public Works and Highways (DPWH)

Contract ID : 21JA0010
Contract Name : CONSTRUCTION OF BY-PASS AND DIVERSION ROADS – NRJ -BALUNO – LA PAZ (SITIO
POLE) DIVERSION ROAD, ZAMBOANGA CITY
Contract Location : ZAMBOANGA CITY
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AFFIDAVIT OF CONFLICT OF INTEREST

Date of Opening of Bids: NOVEMBER 10, 2020

I, ENGR. AL-HASSAN C. HASIMAN, of legal age, with residence and address at 288B Caburihan Canelar,
Zamboanga City, after having been duly sworn to in accordance with law, hereby depose and say:

a. That I have no controlling shareholders in common with another Bidder.

b. That I have not received any direct or indirect subsidy from another Bidder.

c. That I have no same legal representative as that of another Bidder for purpose of this Bid.

d. That I have no relationship, directly or through third parties, that puts it in position to have
access to information about or influence on the Bid of another Bidder or influence the
decisions of the PROCURING ENTITY regarding this bidding process.

e. That I have only one Bid in the bidding process, and I will not allow any participation of a sub-
contractors.

f. That I have no participation as consultant in the preparation of the design or technical

specifications of the works, goods and related services that are the subject of the Bid.

g. That I have no intent to lent or temporary seconded, its personnel to firms or organizations,
which are engaged in consulting services for the preparation related to the procurement for or
implementation of the project, if the personnel would be involved in any capacity on the same
project.

IN FAITH WHEREOF, I hereunto affixed my signature this 13TH day of OCTOBER, 2020, at Zamboanga
City, Philippines.

ENGR. AL-HASSAN C. HASIMAN

Affiant

REPUBLIC OF THE PHILIPPINES)

CITY OF ZAMBOANGA ) S.S.

SUBSCRIBED AND SWORN TO before me this ______ day of ___________________, 2020 in Zamboanga
City, Philippines. Affiant exhibiting to me his Community Tax Certificate No. 5545390 issued on January 7, 2020
at Zamboanga City, Philippines.

Notary Public

Doc. No.
Page No.
Book No.
Series of 2020