7-Public Disclosure Form.docx
DOCX document 37 KB Posted
- Solicitation number
- RFP 27009BDC
- Issued by
- Clark County, Fish Springs CDP, Nevada
About this file
This is a Public Disclosure Form from the Clark County School District in Las Vegas, Nevada, required for vendors and contractors seeking to do business with the District. The form requires disclosure of the applicant's employment history with the District, including dates of employment and separation if applicable. Vendors must list all company officers and key employees, indicating whether they are currently employed by the District or have been employed within the past year. Additionally, the form requires complete disclosure of any personal relationships and financial interests between company representatives and current or former District Board of School Trustees and District authorizing officials. The form explicitly states that failure to disclose all facts relative to conflicts or potential conflicts of interest may result in termination of the contract or agreement.
Completion of this disclosure form is mandatory for all contractors and vendors submitting proposals to the Clark County School District. The District enforces compliance through applicable regulations including 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). The form requires signature by an authorized company representative or individual and must be approved by designated District entities including the Board of School Trustees or Deputy Superintendent/Operations, depending on approval requirements. This disclosure requirement applies to the District's current solicitation for a comprehensive family engagement, student progress, and school-to-home communication platform.
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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 | |
| 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 | |
| 4-Supplier Application Update Form.doc | DOC document | |
| 2-W-9.pdf | ||
| 13-Amendment 1 Data Sharing Amendment.docx | DOCX document | |
| 3-Proposal Submittal Form.doc | DOC document |
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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 .