3-Public Disclosure Form 2-17-26.docx
DOCX document 39 KB Posted
- Attached to
- Beverages for Student Meals
- Solicitation number
- 26027AIT
- Issued by
- Clark County, Nevada
About this file
This is a Public Disclosure Form for the Clark County School District in Las Vegas, Nevada, designed to identify potential conflicts of interest for vendors, contractors, and service providers seeking to conduct business with the District. The form requires disclosure of the applicant's employment history with the District, including current or former employee status within the past year, employment dates, positions held, and termination information. Additionally, vendors must disclose whether company officers or key employees have current or former employment relationships with the District and provide separation dates if applicable.
The form mandates comprehensive disclosure of all personal relationships and financial interests between the company, its officers, and key employees with current and former District Board of School Trustees members and District authorizing officials. Signatories must acknowledge that failure to disclose all facts relative to conflicts or potential conflicts of interest may result in contract termination. The District references applicable regulations governing these requirements, including District Policy 4270 on Conflict of Interest, District Regulation 4371 on Employees' Cooling Off Period, and District Regulation 3312 on Purchasing Authorization and Nepotism. The form requires completion by an authorized company representative or individual and submission for approval by the Board of School Trustees and Deputy Superintendent of Operations, with an internal use section for approval notation and date documentation.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 7-26027AIT Beverages for Student Meals - Proposal.docx | DOCX document | |
| 9-26027AIT Beverages for Student Meals - Attachment Table A (BT-78TY).xlsx | XLSX spreadsheet | |
| 1-Supplier Application Update Form 4-2025.docx | DOCX document | |
| 4-Updated Supplier Federal 2CFR200 Certification Form 10.20.23.pdf | ||
| 5-Supplier Contact List Designation Form 09-2022.pdf | ||
| 8-26027AIT Beverages for Student Meals BOL Attachment B (BT-78QY).xlsx | XLSX spreadsheet | |
| 6-Food Sv RFP T Cs Pur-RFP-002 8-18-25.doc | DOC document | |
| 2-Form W-9 (Rev.pdf |
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: |
| Email address: |
| Phone Number |
For Internal Use
| Approval Required |
| District Entity |
| Signature/Reference |
| Date |
| Board of School Trustees |
| Deputy Superintendent/Operations |
| Approval Not Required |
Updated 2-17-2026 PUR-F0003, Rev. B image1.jpeg
File details come from the government source that posted it. Updated .