1-Disclosure Form 3-15-11.docx
DOCX document 37 KB Posted
- Attached to
- Mathematics Professional Learning Services
- Solicitation number
- RFP 26025TCG
- Issued by
- Clark County, Nevada
About this file
This is a Public Disclosure Form required by the Clark County School District in Las Vegas, Nevada for vendors and contractors seeking to do business with the district. The form serves as a conflict-of-interest certification mechanism, requiring disclosure of employment history with the district, current and former employee relationships among company officers and key personnel, and any personal or financial relationships between company representatives and district board trustees or authorizing officials. Respondents must certify that they are not currently employed by the district and have not been employed within the past year, unless otherwise disclosed. The form requires detailed information about company employees and officers, including their positions, current employment status with the district, and separation dates for former employees.
The disclosure form emphasizes that failure to disclose all facts relative to conflicts or potential conflicts of interest may result in termination of the contract or agreement with the district. The form references applicable district regulations governing conflicts of interest, including District Policy 4270 (Conflict of Interest: All Employees), District Regulation 4371 (Employees "Cooling Off" Period), and District Regulation 3312 (Purchasing Authorization and Nepotism). The document requires signature by an authorized company representative or individual and includes sections for internal district use regarding approval determinations by the Board of School Trustees and Deputy Superintendent of Operations.
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| 3-W-9 2024.pdf | ||
| 6-RFP 26018TCG Proposal Submittal Form.docx | DOCX document | |
| 4-supplier-application-update-form-4-2025-fillable.pdf | ||
| 5-RFP 26018TCG Customer Reference Form.docx | DOCX document | |
| 8-RFP 26025TCG Mathematics Professional Learning Services 7-10-25.pdf | ||
| 2-Updated Supplier Federal 2CFR200 Certification Form 10.20.23.docx | DOCX document | |
| 7-Supplier Contact List Designation Form 09-2022.doc | DOC document |
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Text version
Public Disclosure Form Clark County School District Las Vegas, NV
| Company/Individual’s Name: |
| Federal Tax ID # (EIN or SSN): |
1. Unless otherwise indicated, I certify that I am not currently an employee of the Clark County School District (the “District”) nor have I been an employee of the District within the past year.
2. If the person performing the work was a previous District employee and is self-employed or is an owner or part owner in the company they work for, information must be provided, as follows:
Dates employed with the District: _____________________ Position held _____________________________________ Employment terminated on: ____________________ Last Paycheck date: ____________________________________
3. Unless otherwise indicated, I certify that the officers of this company are not currently employees of the District nor have they been employees of the District within the past year.
Please complete the following. Additional sheets may be attached if necessary. Write “none” if applicable.
| Company Employee Name/Individual’s Name |
| Position within Company |
| Are they Currently a District Employee? |
| Separation Date if a Former District Employee |
4. I certify that I have listed all personal relationships and financial interests between the company, company officers, and key employees with current and former District Board of School Trustees, and current and former District authorizing officials.
Please complete the following. Additional sheets may be attached if necessary. Write “none” if applicable.
| Company Employee Name/Individual’s Name |
| Position within Company |
| Are they Currently a District Official/Trustee? |
| Relationship to/Interest with District Official/Trustee |
5. I hereby acknowledge that failure to disclose all facts relative to a conflict or potential conflict of interest with regard to my contract/agreement with the District may result in termination of said contract/agreement.
(Applicable District Regulations can be accessed on the District website www.ccsd.net . These include District Policy 4270, Conflict of Interest: All Employees; District Regulation 4371, Employees “Cooling Off” Period; and District Regulation 3312, Purchasing Authorization and Nepotism – All Funds.)
| Individual or Authorized Company Representative |
| Signature: |
| Title: |
| Date: |
For Internal Use
| Approval Required |
| District Entity |
| Signature/Reference |
| Date |
| Board of School Trustees |
| Deputy Superintendent/Operations |
| Approval Not Required |
Updated 3-15-2011 PUR-F0003, Rev. A image1.jpeg
File details come from the government source that posted it. Updated .