4-Supplier Public Disclosure Form 3-15-11.docx
DOCX document 38 KB Posted
- Solicitation number
- RFP26019KLP
- Issued by
- Clark County, Fish Springs CDP, Nevada
About this file
This document is a Public Disclosure Form for the Clark County School District in Las Vegas, Nevada, designed to capture potential conflicts of interest for vendors or individuals seeking to do business with the district. The form requires participants to disclose current or recent employment with the district, personal relationships with district officials, and any financial interests that might constitute a conflict of interest.
The form emphasizes transparency and compliance, requiring signatories to list any current or former district employees within their organization, detail any personal relationships with district trustees or officials, and acknowledge that failure to fully disclose potential conflicts could result in contract termination. The form is specifically linked to district regulations including Policy 4270 (Conflict of Interest), Regulation 4371 (Employees "Cooling Off" Period), and Regulation 3312 (Purchasing Authorization and Nepotism), with the document updated on 3-15-2011. The related contract opportunity appears to involve Multi-Function Devices and Related Products and Services for the state of Nevada.
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Other files
| File | Type | Posted |
|---|---|---|
| 3-26019KLP Multi-function Devices and Related Products and Services.doc | DOC document | |
| 7-supplier-application-update-form-4-2025-fillable.pdf | ||
| 9-RFP Submittal Form.doc | DOC document | |
| 8-Supplier Federal 2CFR200 Certification Form 10.20.23.docx | DOCX document | |
| 2-Attachment B - Axia Cooperative Purchasing Program.pdf | ||
| 5-Supplier Contact List Designation Form 09-2022.pdf | ||
| 6-W-9 2024 (3).pdf | ||
| 1-Attachment A - Cost Proposal.xlsx | XLSX spreadsheet |
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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 .