1-Supplier Application Update Form 4-2025.docx

46 KB Posted

Attached to
Beverages for Student Meals
Solicitation number
26027AIT
Issued by
Clark County, Nevada

About this file

Written by GovTribe AI ·

This is a Supplier Application/Update Form issued by the Clark County School District (CCSD) Purchasing Department located in Las Vegas, Nevada. The form is used to register suppliers interested in contracting with CCSD for potential purchases of beverages for the school breakfast and lunch programs throughout the District. The document collects comprehensive supplier information including business registration details, federal tax identification, business status certifications, local physical presence, and employee demographics specific to Nevada and Clark County residency.

The form requires suppliers to provide corporate business address, contact information, and SAP Business Network registration details necessary for purchase order and invoice processing. Suppliers must disclose minority ownership status (MBE, PBE, VBE, WBE), Nevada business licensing, and local physical presence information including building type and location within Clark County or Nevada. The form includes employment data fields requesting the number of Nevada residents, Clark County residents, and non-Nevada residents employed. Suppliers must certify agreement with CCSD's purchase order terms and conditions and federal 2 CFR 200 terms and conditions. The completed and signed form constitutes a self-certification of business size, minority status, and women-owned status, with the form effective as of April 14, 2025.

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9-26027AIT Beverages for Student Meals - Attachment Table A (BT-78TY).xlsx XLSX spreadsheet
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8-26027AIT Beverages for Student Meals BOL Attachment B (BT-78QY).xlsx XLSX spreadsheet
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2-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

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