1-Public Disclosure Form.docx
DOCX document 37 KB Posted
- Attached to
- RFP 26024BDC Grades 6-12 Digital Courseware
- Solicitation number
- RFP 26024BDC
- 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 requires disclosure of the applicant's employment history with the district, including dates of employment, positions held, and separation dates if applicable. Additionally, vendors must disclose all officers and key employees of their company, indicating whether they are current or former district employees and providing separation dates when relevant. The form also requires complete disclosure of any personal relationships and financial interests between company representatives and current or former District Board of School Trustees members or district authorizing officials.
The form serves as a conflict-of-interest disclosure mechanism designed to ensure transparency and compliance with district regulations including District Policy 4270 (Conflict of Interest: All Employees), District Regulation 4371 (Employees "Cooling Off" Period), and District Regulation 3312 (Purchasing Authorization and Nepotism). Vendors and contractors must certify under penalty that they have disclosed all facts relative to potential conflicts of interest, acknowledging that failure to do so may result in contract termination. The form requires signatures from the individual or authorized company representative along with approval from appropriate district entities including the Board of School Trustees and Deputy Superintendent of Operations, where 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 image1.jpeg
File details come from the government source that posted it. Updated .