1-Supplier Application Update Form 4-2025.docx

46 KB Posted

Attached to
Frozen Meat, Entrees, Pizza and Sandwiches
Solicitation number
26020AIT
Issued by
Clark County, Nevada

About this file

Written by GovTribe AI ·

This document is a Supplier Application/Update Form from the Purchasing Department of Clark County School District (CCSD) in Las Vegas, Nevada. The form is associated with a solicitation for frozen meat, entrees, pizza, and sandwiches for school breakfast and lunch programs across the district. The form serves as a vendor registration and qualification document for potential suppliers seeking to participate in the district's procurement process.

The application captures detailed vendor information including business status, ownership type, certification details, and employee demographics. Vendors can self-identify as minority-owned, women-owned, veteran-owned, or disabled-owned businesses, with options for self-certification or agency certification. The form requires vendors to confirm compliance with CCSD's purchase order terms and conditions, federal 2CFR200 terms, and provides fields for tax identification, contact information, and local business presence. Notably, the form includes sections for verifying Nevada state business licensing, local employment numbers, and requires an authorized signature certifying the accuracy of submitted information.

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Other files

File Type Posted
9-26020AIT Balance of Line Discount - Bid Table B BT-17MP.xlsx XLSX spreadsheet
4-Updated Supplier Federal 2CFR200 Certification Form 10.20.23.pdf PDF
8-26020AIT Frozen Meat, Entrees, Pizza and Sandwiches - Table A (BT-45KZ).xlsx XLSX spreadsheet
2-Public Disclosure Form 3-15-11.pdf PDF
5-Supplier Contact List Designation Form 09-2022.pdf PDF
6-Food Sv RFP T Cs Pur-RFP-002 8-18-25.doc DOC document
7-26020AIT Frozen Meat, Entrees, Pizza and Sandwiches - Proposal.docx DOCX document
3-Form W-9 (Rev.pdf PDF

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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 .