4-Disclosure Form 3-15-11.pdf
PDF 43 KB Posted
- Solicitation number
- Bid 25032SGG
- Issued by
- Clark County, Nevada
About this file
This is a Public Disclosure Form from the Clark County School District in Las Vegas, Nevada, designed to identify potential conflicts of interest for vendors or individuals seeking to do business with the district. The form requires disclosure of current and past employment relationships with the district, including details about company employees, officers, and any personal or financial relationships with district board members or officials. The document mandates transparency regarding any potential conflicts that could impact the contractual relationship.
The form emphasizes the importance of full disclosure, warning that failure to reveal all relevant facts about conflicts of interest may result in contract termination. It references specific district policies, including Policy 4270 on Conflict of Interest, Regulation 4371 regarding employee "Cooling Off" periods, and Regulation 3312 on Purchasing Authorization and Nepotism. The form provides spaces for detailing employee information, positions, current district employment status, and any relationships with district officials, with the option to attach additional sheets if necessary.
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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 .