Fairfield Independent School District Vendor Application Form

Transcription

1 Fairfield Independent School District Vendor Application Form Instructions: The application form should be completed and signed by an authorized representative of the vendor. The application should be submitted (as noted below) with all supporting documents, including but not limited to: o Form W9 o Conflict of Interest Questionnaire o Felony Conviction Form o Certificate of Insurance (as appropriate for on-site professional services) o SB9 Certification (if working directly with students) Notice to Prospective Vendors: Vendors are not placed on the district s approved vendor list until a purchase order is approved by the purchasing department. Vendors must accept purchase orders for all purchases. The district will not be responsible for payment for goods or services that are provided to Fairfield ISD staff without an approved purchase order issued by the purchasing department. All invoices must reflect the purchase order number and must be mailed, faxed, or ed to the Fairfield ISD Accounts payable Department (see below). All payments are net 30 days after receipt of the goods and/or services. VENDOR IDENTIFICATION: Vendor name Vendor DBA, if appropriate Federal Tax ID or Social Security Number Type(s) of Goods or Services List any Coop contracts such as TCPN, TIPS, BuyBoard, ESC, etc. VENDOR CONTACT INFORMATION: Mailing Address Phone Number Fax Number Website URL Address: (for distribution of purchase orders) I hereby certify that the above information is true and correct. I further certify that I am an authorized representative of this vendor. Authorized Representative (Print Name) Authorized Representative (Signature) Title Date Forward completed application to: Fairfield ISD, Attn Accts Payable, 615 Post Oak Rd, Fairfield, TX 75840, (fax), or lesley.cain@fairfieldisd.org

2

3 Debarment Notice Form I certify that my company has not been disbarred, suspended, or otherwise made ineligible for participation in Federal Assistance programs under Executive Order 12549, Debarment and Suspension, as described in the Federal Register Rules and Regulations. Signature of Company Official: Printed Name: Title: Date:

4 HB 89 Chapter 2270 Verification I certify that my company does not and will not boycott Israel while doing business with Fairfield ISD. Signature of Company Official: Printed Name: Title: Date:

5 SB 252 Chapter 2252 (f) Verification I certify that my company does not and will not engage in business with Iran, Sudan or a foreign terrorist organization identified on the Texas Comptroller s list while doing business with Fairfield ISD. The list of foreign terrorist organizations can be found on the Texas Comptroller s website. Signature of Company Official: Printed Name: Title: Date:

6

7 Fairfield Independent School District Local Government Officers Superintendent Mr. Tony Price, Superintendent Mrs. Melissa Cox, Deputy Superintendent Board of Trustees Mrs. Tracie Ezell, President Mr. Eric Chavers, Vice President Mrs. Kimberly Whitaker, Secretary Mr. LaCharles Bass, Member Mr. Kevin Benedict, Member Mr. John Fryer, Member Mr. Blake Robinson, Member

8

9

10

11

12 SB 9 Contractor Certification Independent Contractor Introduction: Texas Education Code Chapter 22 requires an independent contractor who provides services to a school district to submit to a criminal history review if the independent contractor will have continuing duties related to the contracted services and direct student contact. Each independent contractor must certify to the district that they have complied. The district may not obtain criminal histories for individual independent contractors: The law requires each contractor to obtain the criminal histories of its covered employees. For more information or to set up an account, a contractor should contact the Texas Department of Public Safety s Crime Records Service at A covered independent contractor with a disqualifying criminal history is prohibited from serving at a school district. The following offenses are disqualifying: (1) a conviction or other criminal history information designated by the District; (2) a felony or misdemeanor offense that would prevent a person from obtaining certification as an educator under Texas Education Code , including an offense listed at 19 Tex. Admin. Code ; or (3) one of the following offenses, if at the time of the offense, the victim was under 18 or enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an offense for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal Procedure; (c) an equivalent offense under federal law or the laws of another state. I certify to Fairfield Independent School District ( District ) that I have obtained all required criminal history record information regarding myself through the Texas Department of Public Safety s Fingerprint-based Applicant Clearinghouse of Texas (FACT). I further certify to the District that I do not have a disqualifying criminal history. I agree to notify the District in writing within 3 business days if I am arrested or adjudicated for a disqualifying reason during the contract term. I agree to provide the District, upon request, my full name and any other requested information so that the District may obtain my criminal history record information. I understand that the District may terminate my services at any time if the District determines, at its sole discretion, that my criminal history is not acceptable. Noncompliance or misrepresentation regarding this certification may be grounds for contract termination. Signature Date Copyright 2009 Texas Association of School Boards. All rights reserved TASB Legal Services

13 SB 9 Contractor Certification Contractor Employees Introduction: Texas Education Code Chapter 22 requires entities that contract with school districts to obtain criminal history records on covered employees. Covered employees with disqualifying criminal histories are prohibited from serving at a school district. Contractors must certify to the district that they have complied and must obtain similar certifications from their subcontractors. The district may not obtain criminal histories for contractors: The law requires each contractor to obtain the criminal histories of its covered employees. For more information or to set up an account, a contractor should contact the Texas Department of Public Safety s Crime Records Service at Definitions: Covered employees: Employees of a contractor who have or will have continuing duties related to the service to be performed at the District and have or will have direct contact with students. The District will be the final arbiter of what constitutes continuing duties or direct contact with students. Disqualifying criminal history: (1) a conviction or other criminal history information designated by the District; (2) a felony or misdemeanor offense that would prevent a person from obtaining certification as an educator under Texas Education Code , including an offense listed at 19 Tex. Admin. Code ; or (3) one of the following offenses, if at the time of the offense, the victim was under 18 or enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an offense for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal Procedure; (c) an equivalent offense under federal law or the laws of another state. On Behalf of ( Contractor ), I, the undersigned authorized signatory for Contractor, certify to Fairfield Independent School District ( District ) that [check one]: [ ] None of Contractor s employees are covered employees, as defined above. If this box is checked, I further certify that Contractor has taken precautions or imposed conditions to ensure that its employees will not become covered employees. Contractor will maintain these precautions or conditions throughout the time the contracted services are provided. Or [ ] Some or all of Contractor s employees are covered employees. If this box is check, I further certify that: Copyright 2009 Texas Association of School Boards. All rights reserved TASB Legal Services

14 (1) Contractor has obtained all required criminal history record information regarding its covered employees. None of the covered employees has a disqualifying criminal history. (2) If Contractor receives information that a covered employee subsequently has a reported criminal history, Contractor will immediately remove the covered employee from contract duties and notify the District in writing within 3 business days. (3) Upon request, Contractor will provide the District with the name and any other requested information of covered employees so that the District may obtain criminal history record information on the covered employees. If the District objects to the assignment of a covered employee on the basis of the covered employee s criminal history record information, Contractor agrees to discontinue using that covered employee to provide services at the District. I also certify to the District on behalf of Contractor that Contractor has obtained certifications from its subcontractors of compliance with Education Code, chapter 22. Noncompliance or misrepresentation regarding this certification may be grounds for contract termination. Signature Date Title Copyright 2009 Texas Association of School Boards. All rights reserved TASB Legal Services