1-Disclosure Form 3-15-11.pdf
PDF 119 KB Posted
- Attached to
- Cash Transit Services
- Solicitation number
- RFP 26023AAP
- Issued by
- Clark County, Nevada
About this file
This is a Public Disclosure Form issued by the Clark County School District in Las Vegas, Nevada, designed to identify potential conflicts of interest and disclosure requirements for vendors and contractors conducting business with the District. The form requires complete disclosure of any current or former employment relationships between the submitting company, its officers, and key employees and the District, including specific dates of employment and termination. Additionally, vendors must disclose all personal relationships and financial interests involving company representatives and current or former District Board of School Trustees members and authorizing officials. The form applies to contractors bidding on District opportunities, including the Cash Transit Services contract, which involves providing secure cash transit services to support the District's Food Service Program and various administrative requirements.
Vendors and their representatives who fail to disclose all relevant facts pertaining to conflicts of interest or potential conflicts of interest risk termination of their contracts or agreements with the District. The disclosure requirements are grounded in District Policy 4270 regarding Conflict of Interest for all employees, District Regulation 4371 addressing the Employees "Cooling Off" Period, and District Regulation 3312 concerning Purchasing Authorization and Nepotism across all District funds. The form requires signature and authorization by a company representative or individual and must be approved by the appropriate District entity, including the Board of School Trustees or Deputy Superintendent of Operations as required.
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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 http://www.ccsd.net/
File details come from the government source that posted it. Updated .