17-supplier-application-update-form-4-2025-fillable.pdf

PUR-F0001 Updated 4/14/2025

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