21-Public Disclosure Form 3-15-11.docx
DOCX document 37 KB Posted
- Attached to
- Biology and Honors Biology Textbook Adoption
- Solicitation number
- RFP 27004TLH
- Issued by
- Clark County, Fish Springs CDP, Nevada
About this file
This is a Public Disclosure Form from the Clark County School District in Las Vegas, Nevada, used to identify potential conflicts of interest and establish compliance with district policies regarding vendor and contractor relationships. The form requires disclosure of the applicant's employment history with the district, including dates of employment and separation if applicable. Contractors and their company officers must disclose whether they are currently or were recently employed by the district within the past year. The form also requires identification of all company employees and officers, their positions, and their current employment status with the district.
The disclosure form mandates complete transparency regarding personal relationships and financial interests between the contractor, company officers, key employees, and current or former Clark County School District Board of School Trustees and authorizing officials. Signatories acknowledge that failure to disclose conflicts of interest or potential conflicts may result in contract termination. The form references applicable district regulations including Policy 4270 on Conflict of Interest for All Employees, Regulation 4371 on the Employees "Cooling Off" Period, and Regulation 3312 on Purchasing Authorization and Nepotism. Internal approval is required from the Board of School Trustees and the Deputy Superintendent/Operations before the form is finalized.
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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 .