4-Supplier Application Update Form.doc

120 KB Posted

Attached to
FAMILY ENGAGEMENT, STUDENT PROGRESS AND SCHOOL-TO-HOME COMMUNICATION APPLICATION
Solicitation number
RFP 27009BDC
Issued by
Clark County, Fish Springs CDP, Nevada

About this file

Written by GovTribe AI ·

This is a Supplier Application/Update Form issued by the Clark County School District (CCSD) Purchasing Department in Las Vegas, Nevada, for vendors seeking to conduct business with the district. The form collects comprehensive supplier information including federal tax identification, business registration details, and contact information necessary for procurement processing. Suppliers must provide their main or corporate business address, establish a SAP Business Network account for purchase order and invoice processing, and designate a point of contact with an accessible email address for purchase order communications. The form also captures information regarding local physical presence in Nevada, specifically within Clark County, and requires suppliers to disclose their employee distribution across Nevada, Clark County, and non-Nevada locations.

The form includes a business status section requiring suppliers to self-certify their ownership classification, including minority-owned (MBE), women-owned (WBE), veteran-owned (VBE), or physically challenged-owned (PBE) designations, along with the certification authority and expiration dates. Suppliers must indicate whether they hold a Nevada State Business License and affirm their agreement to both CCSD's standard Purchase Order Terms and Conditions and Federal 2CFR200 Terms and Conditions. The completed and signed form constitutes a self-certification regarding company size, minority status, and women-owned status. The form was last updated on April 14, 2025, and serves as the foundational documentation for all suppliers seeking to transact with CCSD for the family engagement, student progress, and school-to-home communication platform initiative.

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Other files

File Type Posted
12-RFP 27009BDC Family Engagement, Student Progress, School to Home Communication.doc DOC document
9-Attachment A.docx DOCX document
1-Customer Reference Form.docx DOCX document
7-Public Disclosure Form.docx DOCX document
6-Supplier Federal 2 CFR 200 Certification Form.docx DOCX document
10-Appendix B - System Matrix.xlsx XLSX spreadsheet
11-Appendix A - Pricing Sheet.docx DOCX document
8-Attachment B.docx DOCX document
5-Supplier Contact List Designation Form.doc DOC document
2-W-9.pdf PDF
13-Amendment 1 Data Sharing Amendment.docx DOCX document
3-Proposal Submittal Form.doc DOC document
Show all 12

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Supplier Application/Update Form Purchasing Department

4212 Eucalyptus Avenue Bldg. 7 Las Vegas, NV 89121

Telephone: (702) 799-5225 Fax: (702) 799-5018

Main or Corporate Business Name & Address (as it appears on W-9):
Federal Tax ID Number:
Name:
Have you ever received or are you currently receiving PERS (Public Employees’ Retirement System of Nevada) benefits?
Yes
No
Address:
City:
State:
Zip:
Check here if you are a designated NV Emerging Small Business
Yes
Telephone:
Fax:
SAP Business Network is required for PO and invoice processing

Contact Email Address:

Please provide ANID number if already transacting on SAP Business Network:

PO Email address:

Please use an email address that multiple staff members can access
Are you an integrated Supplier?
Yes
No

Website Address:

Business Status (check all that apply):

Contact Person:

Minority Owned (51% or more owned & managed by minority) - MBE

Local, dba, and/or ordering address – If Different From Main address:
African American
Asian/Asian-Pacific American
Name:
Hispanic American
Native American
Not Applicable
Address:
Physically Challenged Owned (51% or more owned & managed by disabled) PBE
City:
Veteran Owned (51% or more owned & managed by veteran) VBE
State:
Zip:
Women Owned (51% or more owned & managed by women) WBE
Telephone:
Fax:
Is your above status:
Self-Certified
Agency Certified
Email Address:
Certifying Agency:
Website Address:
Certification Number:
Exp. Date:
Contact Person:
Do you have a NV State Business License?
Yes
No
Remit To (exactly as shown on invoice):
NV Business ID #
Exp. Date:

Name:

Local Physical Presence (building location):

Address:
Clark County, NV
Other county in NV
No building in NV
City:
Type of Building (skip if not located in Nevada):
State:
Zip:
Corporate Headquarters
Sales/Retail Outlet
Telephone:
Fax:
Office
Warehouse
Residence
Contact Person:
Other:

Terms & Conditions:

Employees:
How many Nevada Residents do you employ?
Do you agree to CCSD’s PO Terms & Conditions?
No Yes
How many Clark County Residents do you employ?
Do you agree to CCSD’s Federal 2CFR200 Terms & Conditions?
No Yes
How many non-Nevada Residents do you employ?
Total Number of Employees:

BY SIGNING THIS FORM, YOU ARE CERTIFYING THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE AND BELIEF. The completed form, when signed, constitutes a self-certification as to size, minority, and/or women owned status.

Name of Person Authorized to Sign (Please Print):
Title:
Signature:
Date:

Purchasing Internal Use Only

Buyer Initials:
Date Received from Supplier:
Date Entered in Master Data:
Supplier Maintenance Initials:
Admin. Approval for Exceptions

PUR-F0001 Updated 4/14/2025

File details come from the government source that posted it. Updated .