The file's text, extracted by GovTribe without its formatting.
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 |
| 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 |
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: |
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