Contract and Disclosure Form →

Description

CONTRACT AND GRANT DISCLOSURE AND CERTIFICATION FORM Failure to complete all of the following information may result in a delay in obtaining a contract, lease, purchase agreement, or grant award with any Arkansas State Agency. SUBCONTRACTOR: Yes SUBCONTRACTOR NAME: No IS THIS FOR: Goods? TAXPAYER ID NAME: YOUR LAST NAME: Services? Both? FIRST NAME: M.I.: ADDRESS: CITY: STATE: ZIP CODE: --- COUNTRY: AS A CONDITION OF OBTAINING, EXTENDING, AMENDING, OR RENEWING A CONTRACT, LEASE, PURCHASE AGREEMENT, OR GRANT AWARD WITH ANY ARKANSAS STATE AGENCY, THE FOLLOWING INFORMATION MUST BE DISCLOSED: F O R I N D I V I D U A L S * Indicate below if: you, your spouse or the brother, sister, parent, or child of you or your spouse is a current or former: member of the General Assembly, Constitutional Officer, State Board or Commission Member, or State Employee: Mark (√) Position Held Current Former Name of Position of Job Held [senator, representative, name of board/ commission, data entry, etc.] For How Long? From MM/YY To MM/YY What is the person(s) name and how are they related to you? [i.e., Jane Q. Public, spouse, John Q. Public, Jr., child, etc.] Person’s Name(s) Relation General Assembly Constitutional Officer State Board or Commission Member State Employee None of the above applies F O R A N E N T I T Y ( B U S I N E S S ) * Indicate below if any of the following persons, current or former, hold any position of control or hold any ownership interest of 10% or greater in the entity: member of the General Assembly, Constitutional Officer, State Board or Commission Member, State Employee, or the spouse, brother, sister, parent, or child of a member of the General Assembly, Constitutional Officer, State Board or Commission Member, or State Employee. Position of control means the power to direct the purchasing policies or influence the management of the entity.