2-Disclosure Form 3-15-11.pdf
PDF 119 KB Posted
- Attached to
- Lamination Machines and Accessories
- Solicitation number
- Bid 26022HCF
- 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 to identify potential conflicts of interest and employee relationships prior to contract execution. The form requires disclosure of the contractor's current and former employment status with the District, listing of all company officers and key employees along with their employment history with the District, and identification of any personal relationships or financial interests between company representatives and District Board of School Trustees or District authorizing officials. The form serves as a certification mechanism to ensure transparency and compliance with District conflict-of-interest policies.
Contractors and their authorized representatives must acknowledge that failure to disclose all relevant facts regarding conflicts or potential conflicts of interest may result in contract termination. The disclosure requirements reference applicable District regulations including Policy 4270 (Conflict of Interest: All Employees), Regulation 4371 (Employees "Cooling Off" Period), and Regulation 3312 (Purchasing Authorization and Nepotism). The form requires signature by the individual or authorized company representative along with approval by District entities including the Board of School Trustees and Deputy Superintendent/Operations as appropriate.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 http://www.ccsd.net/
File details come from the government source that posted it. Updated .