17-Disclosure Form 3-15-11.docx
DOCX document 37 KB Posted
- Attached to
- Chemistry and Honors Chemistry Textbook Adoption
- Solicitation number
- RFP 27003LMK
- Issued by
- Clark County, Nevada
About this file
This is a Public Disclosure Form for the Clark County School District in Las Vegas, Nevada, used for vendor and contractor qualification purposes. The form requires disclosure of employment history, conflicts of interest, and financial relationships between contracting parties and District personnel. Respondents must certify they are not current District employees or have not been employed by the District within the past year, and must disclose if officers or key employees of their company have current or former employment relationships with the District. The form also requires comprehensive disclosure of any personal relationships or financial interests between company representatives and current or former members of the District Board of School Trustees and District authorizing officials.
The form serves as a conflict-of-interest screening mechanism and is mandatory for contract award consideration. Failure to disclose all relevant facts regarding conflicts or potential conflicts of interest may result in contract termination. Vendors must obtain approval from the Board of School Trustees and Deputy Superintendent of Operations before contract execution. The disclosure requirements align with District Policy 4270 (Conflict of Interest), Regulation 4371 (Employees "Cooling Off" Period), and Regulation 3312 (Purchasing Authorization and Nepotism), all accessible through the District website at www.ccsd.net.
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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 .