6-h. Vendor Conflict of Interest Disclosure.pdf

ROCKFORD PUBLIC SCHOOL DISTRICT NO. 205

VENDOR CONFLICT OF INTEREST DISCLOSURE FORM

DISCLOSURE STATEMENT:

All businesses (“Vendors” or “Vendor” or “Vendor’s”) that wish to conduct business with the Rockford Public

Schools “RPS” must complete this form. Please note that all contracts with RPS are subject to RPS Code of Ethics which prohibits RPS employees and Board of Education members from having certain relationships with persons or entities conducting (or proposing to conduct) business with RPS and which limits the acceptance of gifts from

Vendors. The entire Board Member Conflict of Interest Board Policy 2.100 and Board Policy 5.120 may be viewed at http://www2.rps205.com/District/BOE/Pages/GP-200.aspx. The Code and its definitions are incorporated by reference into this Disclosure Form. If a Vendor has a disclosable relationship, the Vendor should assume the relationship may pose a conflict of interest until notified to the contrary in writing by a RPS administrative staff member authorized to confirm that a determination has been made that a conflict does not exist. A principle of the

Code of Ethics is to ensure that relationships do not influence any official decision or judgment of RPS employees or Board of Education members. Accordingly, disclosure also should be made for any person connected with

Vendor (e.g., officer, director, partner, shareholder, employee,) that is likely to: (i) materially contribute to

Vendor’s preparation, drafting, or presentation of a proposal or bid for services and/or supplies, (ii) materially contribute to Vendor’s negotiation of a contract with RPS, or (iii) perform material services under a contract with

RPS. Below, these persons are referred to as “Disclosable Persons.”

CERTIFICATION:

I hereby certify that, except as disclosed below, to Vendor’s knowledge, there is no conflict of interest involving the Vendor named below that would violate the RPS Code of Ethics, including that: (a) after inquiry, neither

Vendor nor any Disclosable Person is involved or engaged in any private business venture or enterprise, directly or indirectly, with any RPS employee or Board of Education member or his or her family member; (b) no RPS employee or Board member or his or her family member owns or has a material personal financial interest (directly or indirectly) in Vendor or is engaged in a material personal business transaction with Vendor; and (c) no RPS employee or board of Education member or his or her family is employed by Vendor.

I further certify that neither the Vendor nor anyone acting on its behalf has requested that any RPS employee or

RPS Board of Education member exert any influence to secure the award of this bid to the Vendor. Furthermore, no RPS Board of Education member, employee or agent has offered to influence to secure the award of this bid to the Vendor

VENDOR INFORMATION:

Vendor Name:

Vendor Address:

Vendor Phone Number

Vendor Email:

Vendor FEIN:

ROCKFORD PUBLIC SCHOOL DISTRICT NO. 205

VENDOR CONFLICT OF INTEREST DISCLOSURE FORM

DISCLOSURE STATEMENT:

I BELIEVE THE VENDOR NAMED ABOVE DOES have a potential conflict(s) of interest with a current RPS employee(s), or RPS Board of Education member(s).

YES, the above statement is true.

NO, the above statement is NOT true.

If you checked “YES” above, please provide the following information:

List all the Name(s) of RPS employee(s), RPS Board of Education member(s), or RPS employees’ or RPS Board of

Education’s family member(s) with whom there may be a conflict of interest:

1.

2.

3.

Provide a brief description of the nature of the potential conflict(s) of interest:

SIGNATURE:

By my signature below, I certify that I am the Authorized Representative of the VENDOR named above and that all of the information provided above by signor is true and complete to the best of the signor’s knowledge:

Print the Name of the Vendor’s Authorized Representative Print the Position Title of the Vendor’s Authorized Representative

Print the Name of the Vendor’s Authorized Representative Date s s