2-Public Disclosure Form 3-15-11.pdf
PDF 34 KB Posted
- Solicitation number
- 26012AIT
- Issued by
- Clark County, Fish Springs CDP, Nevada
About this file
This document is a Public Disclosure Form for the Clark County School District located in Las Vegas, Nevada. The form is designed to collect information about potential conflicts of interest for individuals or companies seeking to do business with the school district. The form requires disclosure of current and past employment relationships with the district, including details about company employees, their positions, and any connections to district employees or trustees.
The form mandates that respondents certify they are not current district employees or have not been employees within the past year, and requires full disclosure of any personal relationships or financial interests between the company, its officers, and key employees with current or former district officials. The document includes sections for listing employee details, their employment status, and any potential conflicts of interest. Failure to fully disclose such information may result in termination of the contract or agreement. The form references specific district regulations related to conflicts of interest, including Policy 4270, Regulation 4371, and Regulation 3312, which can be found on the district's website (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 http://www.ccsd.net/�
File details come from the government source that posted it. Updated .