6-Disclosure Form 3-15-11.docx
DOCX document 37 KB Posted
- Solicitation number
- RFP 27002JBD
- Issued by
- Clark County, Nevada
About this file
This is a Public Disclosure Form issued by the Clark County School District in Las Vegas, Nevada, designed to identify potential conflicts of interest for vendors, contractors, and their representatives entering into agreements with the district. The form requires disclosure of current and former employment relationships between the company, its officers, and key employees with the school district, including specific dates of employment and separation. Additionally, the form mandates complete disclosure of any personal relationships and financial interests between company representatives and current or former District Board of School Trustees members or district authorizing officials. The disclosure must be completed and signed by an authorized company representative or individual, with approval required from the District's Board of School Trustees and Deputy Superintendent of Operations before contract execution.
The form serves as a conflict-of-interest certification mechanism and acknowledges that failure to disclose relevant facts regarding conflicts or potential conflicts may result in contract termination. Completion of the disclosure is mandatory for all bidders and vendors, with additional sheets permitted for comprehensive listing of relationships and interests. The form references applicable district regulations including District Policy 4270 regarding conflicts of interest for employees, District Regulation 4371 concerning the "Cooling Off" Period for employees, and District Regulation 3312 addressing purchasing authorization and nepotism across all district funds. The form was updated on March 15, 2011, and is designated as PUR-F0003, Revision A.
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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 .