Dickey Manufacturing03/03/2006 FRI 17:57 FAX 630 584 0261 DICKEY MFG CO
03/03/2006 10:26 FAX E179 764 3791 CCS UTILITIES
Joyce Duda = Conflict Disclosure Stalernellt - vendor Questionnair.pdf,
•
X001
2 002
Page
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with loco( governmental entity
FORM CIQ
This questionnaire is being filed In a z rdance With chapter 176 of the Local
Government Code by a person doing business with the governmental entity.
13y law this questionnaire must be filed with the reoords administrator of the
local government not later then the 7th busineee day alar the date the person
becomes aware of facts that require the statement to be filed, See Section
176.006, Local Government Code.
A person rnrnrnitts an offense if the person violates Section 176.006, Local
Government Code. An offense under this section is a Class C misdemeanor.
U Nameofpersondoingbuslneeewlthlocalgovommantalenthy.
OFF cE US EONLY
Date Romrwd
Check thlabow Ifyouaro fling anupdaistoaprevtomtjrfliedqupgtbnhalrc.
(The law requires treat you filo on updated completed querr6or nnlrn mth inc appropriate lir authority not lefty them
September 1 of ane year fcr which en a ±4ly described In Sedion 176.006(a), Local Government Code, Is pending and
not Iota Ithan the 7thbusinass day agar thedalethaoriginallyfledquestionnairebecomesincompleteorinea rate.)
Name each am ployoe or contractor of the Imal gci urnmaneil entity who malree recommendations to a local government
officerofthe go vemmerttalentity With Iti5peck toespendibJ►ea of money AND deo0tlbettrodrflliatlonorbet Iness rolationshtp.
4
Name each kealgovammentafticurwho appoirrte or employe 10=190rornmont uffioun: oftho govemmerrfal entity for
which this clues donnaire is fgodANDdsacriba the affiliation orbuahneaa retationahlp.
Post -it'" brand fax transmittal memo 7671
#of pages ► 4
To.t.
Fr�
Dept.
Phone #
Fax#971
•379/
7GL/• 379/
Fax
v-c),„)G
03/03/2006 FRI 17:57 FAX 630 584 0261
uaiva«uuts 1O:Z6 FAX 978 764 3791
DICKEY MFG CO
CCS UTILITIES
Joyce Duda - Conflict Disclosure Statement - Vendor Questionnaire.pdf
2002
I003
CONFLICT OF INTEREST QUESTIONNAIRE
For Vendor or other person doing business With local governmental entity
FORM CIQ
Page 2
Nara flooallprenvner►.adfoerwlthwbOITIMerhasaffi7Rttionorbuslnessrelatlonehlp, (Complete this section only
1f tho a ruwa r to A, B, or C Is Y.
9.
This smdion, flim 5 including subparts A, B, C & D, =St be completed for each officer WTI whore Me filer has aAfsation or oI yr
relationship. Ansoti additional petits m I,l6 Foran C1Q eo necaeaery.
A- to the local slovemmvrrtoliker named in No section reoetvIng or illccly to re®lvq tiaist4e %name from the filer or the
questionnaire?
Yes
No
6. Is the filer of lhp quItstlonneire receiving or likely to receive taxable Inmrne from or al to direction of the local goner nrrent
officer neral in !hie section AND the twable inoornn isnaltom he local governmental amity?
Yes
C. ISTro filor of thisgvesBonnefre affiliated wN, a rarporaean or other busirlcsSon* thatthe local poVDrnmentof6rer asrWa
aa en (Aker or clinic/or, or holds an ownership of TO peroentcr more?
nV"
D. OoaQfbe ead, aKJlallon or business relationship_
Signise d F.rlon dON Dusfnzr,s with the gunnifrrunIsi endo Data
Atorrod 11IRf23,1
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