1-Supplier Application Update Form 4-2025.docx

46 KB Posted

Attached to
Granola, Plain or Flavored, WG, Individual Serving
Solicitation number
26012AIT
Issued by
Clark County, Fish Springs CDP, Nevada

About this file

Written by GovTribe AI ·

This document is a Supplier Application/Update Form from the Clark County School District (CCSD) Purchasing Department located in Las Vegas, Nevada. The form is associated with a state and local contract opportunity for procuring granola for student meals in school breakfast and lunch programs throughout the district. The contract aims to establish suppliers and spend authorization for individual serving plain or whole grain flavored granola products.

The application form provides a comprehensive template for potential suppliers to self-certify their business status, including minority, veteran, women, and disabled-owned business classifications. Suppliers must provide details such as federal tax ID, business licensing information, contact details, and employment data regarding Nevada and Clark County residents. The form requires agreement to CCSD's purchase order terms and conditions, including federal 2CFR200 compliance. Suppliers must indicate their local physical presence, business type, and provide certification of the information's accuracy through an authorized signature. The form appears to be updated for use through April 14, 2025, and is part of the district's supplier qualification and procurement process.

View the file

Other files

File Type Posted
11-26012AIT Addendum 1 QA.pdf PDF
5-Supplier Contact List Designation Form 09-2022.pdf PDF
7-26012AIT Granola, Plain or Flavored WG - Attachment A (BT-37QZ).xlsx XLSX spreadsheet
10-26012AIT Addendum 1 QA.pdf PDF
8-26012AIT Granola, Plain or Flavored WG - (BOL) Attachment B (BT-46BC).xlsx XLSX spreadsheet
3-Form W-9 (Rev.pdf PDF
4-Updated Supplier Federal 2CFR200 Certification Form 10.20.23.pdf PDF
9-26012AIT Granola, Plain or Flavored, WG.docx DOCX document
2-Public Disclosure Form 3-15-11.pdf PDF
6-Food Sv RFP T Cs Pur-RFP-002 1-2-24 (1).doc DOC document

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Supplier Application/Update Form Purchasing Department 4212 Eucalyptus Avenue Bldg. 7 Las Vegas, NV 89121 Telephone: (702) 799-5225 Fax: (702) 799-5018

Main or Corporate Business Name & Address (as it appears on W-9):
Federal Tax ID Number:
Name:
Have you ever received or are you currently receiving PERS (Public Employees’ Retirement System of Nevada) benefits?
|_| Yes
|_| No
Address:
City:
State:
Zip:
Check here if you are a designated NV Emerging Small Business
|_| Yes
Telephone:
Fax:
SAP Business Network is required for PO and invoice processing
Contact Email Address:
Please provide ANID number if already transacting on SAP Business Network:

PO Email address:

Please use an email address that multiple staff members can access
Are you an integrated Supplier?
|_| Yes
|_| No
Website Address:
Business Status (check all that apply):

Contact Person:

Minority Owned (51% or more owned & managed by minority) - MBE

Local, dba, and/or ordering address – If Different From Main address:
|_| African American
|_| Asian/Asian-Pacific American
Name:
|_| Hispanic American
|_| Native American
|_| Not Applicable
Address:
|_| Physically Challenged Owned (51% or more owned & managed by disabled) PBE
City:
|_| Veteran Owned (51% or more owned & managed by veteran) VBE
State:
Zip:
|_| Women Owned (51% or more owned & managed by women) WBE
Telephone:
Fax:
Is your above status:
|_| Self-Certified
|_| Agency Certified
Email Address:
Certifying Agency:
Website Address:
Certification Number:
Exp. Date:
Contact Person:
Do you have a NV State Business License?
|_| Yes
|_| No
Remit To (exactly as shown on invoice):
NV Business ID #
Exp. Date:

Name:

Local Physical Presence (building location):

Address:
|_| Clark County, NV
|_| Other county in NV
|_| No building in NV
City:
Type of Building (skip if not located in Nevada):
State:
Zip:
|_| Corporate Headquarters
|_| Sales/Retail Outlet
Telephone:
Fax:
|_| Office
|_| Warehouse
|_| Residence
Contact Person:
|_|Other:

Terms & Conditions:

Employees:
How many Nevada Residents do you employ?
Do you agree to CCSD’s PO Terms & Conditions?
|_| Yes |_| No
How many Clark County Residents do you employ?
Do you agree to CCSD’s Federal 2CFR200 Terms & Conditions?
|_| Yes |_| No
How many non-Nevada Residents do you employ?
Total Number of Employees:

BY SIGNING THIS FORM, YOU ARE CERTIFYING THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE AND BELIEF. The completed form, when signed, constitutes a self-certification as to size, minority, and/or women owned status.

Name of Person Authorized to Sign (Please Print):
Title:
Signature:
Date:

Purchasing Internal Use Only

Buyer Initials:
Date Received from Supplier:
Date Entered in Master Data:
Supplier Maintenance Initials:
Admin. Approval for Exceptions

PUR-F0001 Updated 4/14/2025 image1.jpeg

File details come from the government source that posted it. Updated .