6-Supplier Application Update Form.doc

120 KB Posted

Attached to
RFP 26024BDC Grades 6-12 Digital Courseware
Solicitation number
RFP 26024BDC
Issued by
Clark County, Nevada

About this file

Written by GovTribe AI ·

This is a Supplier Application/Update Form for the Purchasing Department of the Clark County School District (CCSD) in Las Vegas, Nevada, used to establish or maintain vendor eligibility for procurement opportunities including RFP 26024BDC for Grades 6-12 Digital Courseware. The form captures comprehensive business information required for vendors to transact with CCSD, including corporate details, tax identification, contact information, and business classification. Suppliers must provide their main business address, federal tax ID, telephone, fax, and email contacts, along with a designated PO email address accessible to multiple staff members. Vendors are required to register on the SAP Business Network for purchase order and invoice processing and must indicate whether they maintain an integrated supplier status and local physical presence in Nevada.

The form requires vendors to self-certify their business status across multiple categories including minority-owned (MBE), physically challenged-owned (PBE), veteran-owned (VBE), and women-owned (WBE) enterprises, with documentation of certifying agencies and certification numbers where applicable. Suppliers must confirm Nevada state business licensing, provide employment data broken down by Nevada residents, Clark County residents, and non-Nevada residents, and explicitly agree to CCSD's PO Terms and Conditions and Federal 2CFR200 Terms and Conditions. The form requires authorization by a company representative and includes internal CCSD tracking fields for buyer initials, receipt dates, master data entry, and administrative approval for exceptions, with the document effective as of April 14, 2025.

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12-RFP26024BDC Appendix A Pricing Sheet.docx DOCX document
8-Cert Destruction-Return of Data - Attachment B 12.6.21.docx DOCX document
2-Customer Reference Form.docx DOCX document
9-Data Share Amendment.docx DOCX document
10-DSA Schedule of Data Attachment A 7-17-25.docx DOCX document
11-Appendix B Systems Matrix.xlsx XLSX spreadsheet
4-Proposal Submittal Form.doc DOC document
13-RFP 26024BDC Grades Digital Courseware.doc DOC document
5-W-9.pdf PDF
3-Supplier Federal 2 CFR 200 Certification Form.docx DOCX document
7-Supplier Contact List Designation Form.doc DOC document
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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 .