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HomeMy WebLinkAboutCentral Texas ConstructionCONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person committs an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. 1. Name of person doing business with local governmental entity. 2. Leis }cad T6 oNSdio16 FORM CIQ OFFICE USE ONLY Date Received Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. El Glenn Brown, City Manager ❑ Robert Alley, Fire Chief ❑ Pete Caler, Landfill Mgr. ❑ David Gwin, Economic Dev. ❑ David Massey, Electric El Lance Simms, Planning & Dev ❑ Cheryl Turney, Purchasing Mgr. ❑ Terry Childers, Deputy City Mgr ❑ Steve Beachy, Parks & Rec ❑ Harvey Cargill, City Attorney Cl Connie Hooks, City Secretary ❑ Becky Nugent, Public Relations ❑ Mark Smith, Public Works ❑ John Woody, W/WW ❑ Kathy Merrill, Asst. City Mgr. ❑ Olivia Burnside, Inf. Tech. ❑ Michael Clancey, Police Chief ❑ Jeff Kersten, Chief Fin.Officer ❑ Julie O'Connell, Human Resources ❑ Ed Spillane, Municipal Judge 944 ONE Describe each affiliation or business relationship with an employee checked in Question 3 above: 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is the subject of this questionnaire. City of College Station Elected Officials College Station City Council ❑ Ron Silvia, Mayor ❑ Ben White, Place 1 ❑ Ron Gay, Place 3 ❑ Lynn Mcllhaney, Place 4 ❑ David Ruesink, Place 6 NONE City of College Station Committees, Boards, and Commissions ❑ John Happ, Place 2 ❑ Chris Scotti, Place 5 ❑ Larry Ringer, Chairman ❑ Mary Fran Troy ❑ Sonio Margarita Gangotena ❑ Sarah Adams, Chair ❑ James Batenhorst ❑ David Chester ❑ Donald Braune ❑ Dan B. Sears, Chairman ❑ Mike Lane ❑ Steve Parker, alternate 1, NONE B/CS Library Committee ❑ Katherine Edwards ❑ Jeanne Mitchell O James Bradford Cemetery Committee O Virginia Reese ❑ Weldon Kruger O RC Slocum NONE Construction Board of Adjustments and Appeals/Building & Standards Commission ❑ Frank Cox ❑ Larry D. Patton ❑ Glenn Thomas, alternate ❑ Don Scherr ❑ B. Carroll Johnson NONE ❑ Kevin Myers ❑ Joe Wallace ❑ James Matson ❑ David Hart ❑ Charles Thomas, alternate ❑ Quinn Williams ❑ Hillary Jessup, Chairman ❑ Haskell Monroe ❑ Ernie Wright NONE O Tedi Ellison O Rusleen Maurice 9. NONE ❑ Jodi Warner, Chair ❑ Shawn Rhodes ❑ John Crompton il\NONE ❑ John Nichols, Chair ❑ Marsha Sanford ❑ Harold Strong ❑ Rick Heaney ❑ Alan King ❑ Susie Cox, alternate ❑ Jay Goss, Chair ❑ Denise Whisenant ONE Historic Preservation Committee ❑ Bill Lancaster O Jane Hughey ❑ Neal Nutall, Jr. Joint Relief Funding Review Committee ❑ J. Kevin Byrne O Reba Ragdale Parks and Recreation Board ❑ Kathleen Ireland ❑ Jody Ford O Harry Green Planning and Zoning Commission ❑ Glenn Schroeder O Dennis Christiansen 41, NONE Design Review Board O Hunter Goodwin O Ward Wells O Robert Rayburn, alternate Zoning Board of Adjustments ❑ Joshua Benn O Donald Braune ❑ Marguerite Anthony O Meredith Waller ❑ Colleen Risinger ❑ Deborah Deitering 0 ❑ Joan Perry ❑ Gary Thomas ❑ Gary Erwin ❑ Derek Dictson ❑ Bill Davis ❑ Nancy Sawtelle ❑ John Nichols NONE El John Richards O Thomas Mather ❑ Larry Hodges O Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard O Don Lewis O Gregg Baird O Chad Jones O Stephen Syptak, Chair O Tom Kirkland 1 NONE O Hugh Lindsay, Area I ❑ John Crompton, Area II ❑ Steve Arden, Area III O Hugh Stearns, Area IV ❑ Andrew Burleson, Student Resident ❑ Dorthea Robinson, Alternate, ETJ Resident O Chris Scotti, Councilmember O Hillary Jessup, Historic Preservation O Lloyd Wasserman, County Commission Research Valley Partnership Board of Directors ❑ Larry Marion ANONE Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ James Massey Outside Agency Funding Review ❑ Charles Taylor Cl Sheryl Welford NONE Northgate Tax Increment Finance Board O David Scarmardo ❑ Glenn Thomas Comprehensive Plan Committee El John Richards, Area I ❑ Brian Bochner, Area II ❑ Laurie Corbelli, Area III ❑ Jerry Cooper, Area IV ❑ Kristina Campbell, Alternate, Student Resident ❑ Craig Hall, Resident -At -Large ❑ Lynn Mcllhaney, Alternate, Councilmember ❑ Gary Erwin, Parks & Rec ❑ Larry Haskins, Northgate District Assoc. ❑ Chris Scotti, Councilman ❑ Marc Chaloupka s°U NONE ❑ Roger Reese ❑ Carolyn Berrow ❑ Anne Jackson ❑ Dale O'Reiley Cl David Hart, Alternate, Area I ❑ Dennis Corrington, Alternate, Area H ❑ Tom Taylor, Alternate, Area III CI Adrian Williams, Alternate, Area IV ❑ Douglas Rape', ETJ Resident ❑ Mike Guido, Alternate, Resident -At -Large ❑ Bill Davis, P&Z ❑ Kathleen Ireland, Parks & Rec Alternate ❑ Bo Miles, Building & Land Development ❑ Larry Marriott, Home Builders Assoc. ❑ Tedi Ellison, Intergovernmental Comm/Chamber of Commerce ❑ James Massey, Intergovernmental Comm/TAMU Admin O Dr. Clark Ealy, Intergovernmental Comm/CSISD ❑ Chuck Martinez, Intergovernmental Comm/ Research Valley Patnership ❑ Linda LaSut, Intergovernmental Comm/MPO O Lindsey Guindi, Intergovernmental Comm/Chamber of Commerce O Rodney Weis, Intergovernmental Comm/TAMU Transit ❑ Dr. Colleen Netterville, Intergovernmental Comm/BISD O Margie Lucas, Intergovernmental Comm/ Brazos Transit District ❑ Chad Bohne, Intergovernmental Comm/TxDOT O Michael Parks, Intergovernmental Comm/BVCOG ❑ Gary Arnold, Intergovernmental Comm/Brazos County Sheriff O Gary Teston, Intergovernmental Comm/ Easterwood Airport ft NONE The following individuals are appointed by the City Council to represent the City of College Station on joint committees with other governmental agencies and community groups. Brazos County Health Department O Lynn Mcllhaney ❑ Ben White C,NONE Brazos Valley Council of Governments ❑ Ron Silvia, Mayor 10 NONE B/CS Metropolitan Planning Organization ❑ Ron Silvia, Mayor lk, NONE BVCOG TMPA Regional Park Project Advisory Board O Lynn Mcllhaney li NONE BVSWMA Policy Advisory Board O Ron Silvia, Mayor El Chris Scotti .9k NONE City Center Committee ❑ Ron Silvia 0 Ben White 0 Dave Ruesink 4 NONE Intergovernmental Committee ❑ Ron Gay ❑ Ben White ❑ John Happ NONE ❑ Dave Ruesink 1 1 NONE 0 Dave Ruesink Joint City/School Intergovernmental Committee 0 Ben White 0 John Happ Sister Cities Association NONE Transportation Committee ❑ Ron Gay 0 John Happ ❑ Lynn Mcllhaney ❑ Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI ❑ Michael Parker, BVCOG 0 Bryan Woods, TxDOT A NONE ❑ Ron Gay ❑ John Nichols ❑ Joan Perry Wolf Pen Creek Oversight Committee ❑ Chris Scotti ❑ Marsha Sanford ❑ Sharon Colson ❑ Marc Chaloupka ❑ Jodi Warner NONE Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or other relationship. Attach additional pages to this Form CIQ as necessary. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. FORM CIQ A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? Yes No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? Yes No C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each affiliation or business relationship. 6. Signature of person doing business w. h the governmental entity Date Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person committs an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. W r&/ Texas C`ot s9 rf C I r /(-) 1. Name of person doing business with local governmental entity. FORM CIQ OFFICE USE ONLY Date Received 2. RCheck this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Describe each affiliation or business relationship with an employee or contractor of the local governmental entity who makes recommendations to a local government officer of the local governmental entity with respect to expenditure of money. ❑ Robert Alley, Fire Chief ❑ Steve Beachy, Parks & Rec ❑ Glenn Brown, City Manager ❑ Olivia Burnside, Inf. Tech. ❑ Pete Caler, Landfill Mgr. ❑ Harvey Cargill, City Attorney ;/(1 NONE ❑ Michael Clancey, Police Chief ❑ Lance Simms, Planning & Dev ❑ John Woody, W/WW ❑ Terry Childers, Deputy City Mgr ❑ Connie Hooks, City Secretary ❑ Jeff Kersten, Chief Fin.Officer 0 ❑ Becky Nugent, Public Relations ❑ Julie O'Connell, Human Resources ❑ Mark Smith, Public Works ❑ Ed Spillane, Municipal Judge ❑ Cheryl Turney, Purchasing Mgr. ❑ David Massey, Electric Describe each affiliation or business relationship with an employee checked in Question 3 above: 4. Describe each affiliation or business relationship with a person who is a local government officer and who appoints or employs a local government officer of the local government entity that is the subject of this questionnaire. ❑ Ron Silvia, Mayor ❑ Ron Gay, Place 3 ❑ David Ruesink, Place 6 City of College Station Elected Officials College Station City Council ❑ Ben White, Place 1 ❑ Lynn Mcllhaney, Place 4 NONE ❑ John Happ, Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions ❑ Larry Ringer, Chairman ❑ Mary Fran Troy ❑ Jennifer Bohac ❑ Sarah Adams, Chair ❑ James Batenhorst ❑ David Chester ❑ Donald Braune ❑ Dan B. Sears, Chairman ❑ Mike Lane ❑ Steve Parker, alternate XNONE B/CS Library Committee ❑ Katherine Edwards ❑ Jeanne Mitchell ❑ James Bradford Cemetery Committee ❑ Virginia Reese ❑ Weldon Kruger ❑ RC Slocum 7NONE Construction Board of Adjustments and Appeals/Building & Standards Commission ❑ Frank Cox ❑ Larry D. Patton ❑ Glenn Thomas, alternate ❑ Don Scherr ❑ B. Carroll Johnson )9rNONE ❑ Kevin Myers ❑ Joe Wallace O James Matson ❑ David Hart O Charles Thomas, alternate O Quinn Williams ❑ Hillary Jessup, Chairman ❑ Haskell Monre ❑ Ernie Wright NONE ❑ Rebecca Eplen ❑ Rusleen Maurice 71" NONE ❑ Jodi Warner, Chair ❑ Shawn Rhodes ❑ John Crompton 7(NONE Historic Preservation Committee ❑ Bill Lancaster ❑ Dipankar Sen ❑ Neal Nutall, Jr. Joint Relief Funding Review Committee ❑ J. Kevin Byrne ❑ Charlotte Mikulee Parks and Recreation Board ❑ Kathleen Ireland ❑ Jody Ford ❑ Harry Green Planning and Zoning Commission ❑ John Nichols, Chair 0 Glenn Schroeder ❑ Marsha Sanford 0 Dennis Christiansen ❑ Harold Strong ,NONE Design Review Board ❑ Marguerite Anthony ❑ Thomas Taylor ❑ Colleen Risinger ❑ Deborah Deitering ❑ Peggy Samson ❑ Joan Perry ❑ Gary Thomas ❑ Gary Erwin O Derek Dictson O Bill Davis ❑ Rick Heany 0 Hunter Goodwin 0 Nancy Sawtelle ❑ Alan King 0 Ward Wells 0 John Nichols ❑ Susie Cox, alternate 0 Robert Rayburn, alternate ' NONE ❑ Jay Goss, Chair ❑ Denise Whisenant )( NONE Zoning Board of Adjustments ❑ Joshua Benn ❑ Donald Braune O John Richards O Thomas Mather ❑ Larry Hodges ❑ Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard ❑ Don Lewis ❑ Gregg Baird ❑ Chad Jones ❑ Stephen Syptak, Chair ❑ Tom Kirkland g NONE ❑ Hugh Lindsay, Area I ❑ John Crompton, Area II ❑ Steve Arden, Area III ❑ Hugh Stearns, Area IV ❑ Andrew Burleson, Student Resident ❑ Dorthea Robinson, Alternate, ETJ Resident ❑ Chris Scotti, Councilmember Research Valley Partnership Board of Directors ❑ Larry Mariott jd NONE Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ James Massey Outside Agency Funding Review ❑ Charles Taylor ❑ Sheryl Welford 'NONE Northgate Tax Increment Finance Board O David Scarmardo O Glenn Thomas Comprehensive Plan Committee ❑ John Richards, Area I ❑ Brian Bochner, Area II ❑ Laurie Corbelli, Area III ❑ Jerry Cooper, Area IV ❑ Kristina Campbell, Alternate, Student Resident ❑ Craig Hall, Resident -At -Large ❑ Lynn Mcllhaney, Alternate, Councilmember O Chris Scotti, Councilman ❑ Marc Chaloupka ❑ NONE ❑ Roger Reese ❑ Carolyn Berrow ❑ Anne Jackson ❑ Dale O'Riley ❑ David Hart, Alternate, Area I ❑ Dennis Corrington, Alternate, Area n ❑ Tom Taylor, Alternate, Area III ❑ Adrian Williams, Alternate, Area IV O Douglas Rape', ETJ Resident ❑ Mike Guido, Alternate, Resident -At -Large Ar NONE The following individuals are appointed by the City Council to represent the City of College Station on joint committees with other governmental agencies and community groups. Brazos County Health Department O Lynn Mcllhaney 0 Ben White NONE Brazos Valley Council of Governments O Ron Silvia, Mayor yi NONE B/CS Metropolitan Planning Organization O Ron Silvia, Mayor y- NONE BVCOG TMPA Regional Park Project Advisory Board O Lynn Mcllhaney ,kr NONE BVSWMA Policy Advisory Board O Ron Silvia, Mayor 0 Chris Scotti 121 NONE City Center Committee ❑ Ron Silvia 0 Ben White 0 Dave Ruesink Ft/NONE Intergovernmental Committee ❑ Ron Gay 0 Ben White 0 John Happ y NONE O Dave Ruesink NONE Joint City/School Intergovernmental Committee 0 Ben White 0 John Happ Sister Cities Association O Dave Ruesink )(NONE Transportation Committee ❑ Ron Gay 0 John Happ 0 Lynn Mcllhaney ❑ Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI ❑ Michael Parker, BVCOG 0 Bryan Woods, TxDOT NONE O Ron Gay Wolf Pen Creek Oversight Committee 0 Chris Scotti NONE Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or other relationship. Attach additional pages to this Form CIQ as necessary. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? Yes No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? Yes No C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each affiliation or business relationship. 6. (i-.11,1 /164 Signature of person doing business with the governmental entity Date Adopted 01/13/06 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity This questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the governmental entity. By law this questionnaire must be filed with the records administrator of the local government not later than the 7th business day after the date the person becomes aware of facts that require the statement to be filed. See Section 176.006, Local Government Code. A person committs an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. 1. Name of person doing business with local governmental entity. aitiRPL TIKRS eoserRuc7-e/til 2. FORM CIQ OFFICE USE ONLY Date Received Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of the year for which an activity described in Section 176.006(a), Local Government Code, is pending and not later than the 7th business day after the date the originally filed questionnaire becomes incomplete or inaccurate.) 3. Name each employee or contractor of the local governmental entity who makes recommendations to a local government officer of the governmental entity with respect to expenditures of money AND describe the affiliation or business relationship. Robert Alley, Fire Chief Charles McLemore, Public Works • ■ Michael Clancey, Police Chief ■ Steve Beachy, Parks & Rec Becky Nugent, Public Relations • ■ Joey Dunn, Planning & Dev ■ Glenn Brown, City Manager Julie O'Connell, Human Resources • ■ Don Fazzino, Legislative Liason ■ Olivia Burnside, Inf. Tech. Mark Smith, Public Works ■ ■ Kim Foutz, Economic Dev ■ Pete Caler, Landfill Mgr. Ed Spillane, Municipal Judge ■ ■ Connie Hooks, City Secretary ■ Harvey Cargill, City Attorney ❑ Jeff Kersten, Finance Cheryl Turney, Purchasing Mgr. • ■ John Woody, Utilities to NONE ■ 4. Name each local government officer who appoints or employs local government officers of the governmental entity for which this questionnaire is filed AND describe the affiliation or business relationship. City of College Station Elected Officials City of College Station Committees, Boards, and Commissions B/CS Library Committee College Station City Council ❑ Larry Ringer, Chairman 0 Katherine Edwards 0 Don Scherr Ron Silvia, Mayor ■ George McLean, Vice Chair ■ Frank Cox John Happ, Place 2 ■ ■ Ben White, Place 1 ■ N NONE Ron Gay, Place 3 ■ James Bradford ■ David Chester Chris Scotti, Place 5 • ■ Susan Lancaster, Place 4 ■ Nancy Berry, Place 6 W. NONE • City of College Station Committees, Boards, and Commissions B/CS Library Committee ❑ Larry Ringer, Chairman 0 Katherine Edwards 0 Don Scherr 0 Eric Miller ■ George McLean, Vice Chair ■ Frank Cox ■ Jeanne Mitchell ■ Jo Berg ■ Mary Lind Bryan ■ Joe Wallace N NONE ■ Lois Koontz ■ James Bradford Cemetery Committee 0 Sarah Adams, Chair 0 Virginia Reese • Kevin Myers ■ George McLean, Vice Chair ■ Frank Cox ❑ Joey Dunn, Dir. Planning & Dev It James Batenhorst ■ Mary Lind Bryan ■ Joe Wallace ■ Larry D. Patton NONE ■ David Chester Construction Board of Adjustments and Appeals/Building & Standards Commission • Dan B. Sears, Chairman ■ George McLean, Vice Chair ■ Frank Cox ❑ Joey Dunn, Dir. Planning & Dev 0 David Hart, alternate ■ Mike Lane ■ Larry D. Patton E. NONE Pi NONE • Steve Parker, alternate ■ David Ruesink, alternate Facade Improvement Program Advisory Committee ■ Karen Kasper, Merchant ■ Valerian Miranda, Architect ■ Rick Lemmons, Business Owner ❑ Joey Dunn, Dir. Planning & Dev ■ Robert Mosley, City Engineer ■ Eric Barton, CD Coordinator E. NONE Historic Preservation Committee Joint Relief Funding Review Committee ❑ Hillary Jessup, Chairman ❑ Bill Lancaster • Marsha Crenwelge ❑ Marguerite Anthony Mary Sherwood • David Ruesink ■ Dipankar Sen ■ ■ ❑ Neal Nutall, Jr. • Thomas Taylor • Ernie Wright Peggy Samson 'fl NONE ■ ■ Colleen Risinger Design Review Board Joint Relief Funding Review Committee Parks and Recreation Board ❑ Hunter Goodwin Rebecca Eplen Kathleen Ireland Mary Sherwood • • J. Kevin Byrne ■ ■ Rusleen Maurice E/ Charlotte Mikulee Carol Blaschke Peggy Samson • ■ Gary Thomas NONE ■ ■ • Design Review Board Parks and Recreation Board ❑ Hunter Goodwin • Rick Heany Kathleen Ireland Glenn Schroeder Jodi Warner • ■ ■ Carol Blaschke • Susie Cox, alternate Jeannie McCandless Gary Thomas • ■ ■ John Crompton Harry Green cs NONE Gary Erwin • ■ ■ q NONE Design Review Board Planning and Zoning Commission ❑ Hunter Goodwin • Rick Heany Scott Shafer, Chairman John Nichols Ken Reynolds • ■ ■ Marsha Sanford • Susie Cox, alternate Dennis Christiansen Bill Davis ■ ■ ■ Harold Strong NONE cs NONE • ■ Design Review Board Zoning Board of Adjustments ❑ Hunter Goodwin • Rick Heany ■ Nancy Sawtelle Joshua Benn ■ Alan King ■ Ward Wells ■ Scott Shafer ■ 1'1 NONE • Susie Cox, alternate ■ Robert Rayburn, alternate 1 Zoning Board of Adjustments Jay Goss, Chair Joshua Benn John Richards • ■ ■ Graham Sheffy Donald Braune Charles Taylor • ■ ■ Denise Whisenant Derek Dictson cs NONE • ■ Research Valley Partnership Board of Directors Wolf Pen Creek TIF Board David Hickson Sharon Colson, Chair Chris Scotti, Councilman • ■ Larry Mariott ■ ■ Glenn Brown, City Manager 01 NONE Kenny Mallard • Wolf Pen Creek TIF Board Sharon Colson, Chair Marsha Sanford, Vice Chair Marc Chaloupka • ■ ■ Kenny Mallard James Massey l NONE ■ ■ CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or other relationship. Attach additional pages to this Form CIQ as necessary. 5. Name of local government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, B, or C is YES. A. Is the local government officer named in this section receiving or likely to receive taxable income from the filer of the questionnaire? 1 Yes No B. Is the filer of the questionnaire receiving or likely to receive taxable income from or at the direction of the local government officer named in this section AND the taxable income is not from the local governmental entity? Yes No C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local government officer serves as an officer or director, or holds an ownership of 10 percent or more? Yes No D. Describe each affiliation or business relationship. 6. CLVI L) 61,,(,)) / 1;XGA s 6ter2 C T; Signature of person doing business with the governmental entity Date Adopted 1110212005