Hospice Brazos Valley, Inc.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.
440tPice toaktD6 VALLEY WC,- J01-11•1 ro5T QQxtoe-xrc( e—o
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. 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
❑ John Woody, Utilities
❑ Michael Clancey, Police Chief
❑ Joey Dunn, Planning & Dev
❑ Don Fazzino, Legislative Liason
❑ Kim Foutz, Economic Dev
❑ Connie Hooks, City Secretary
❑ Jeff Kersten, Finance
O NONE
Describe each affiliation or business rel
El Charles McLemore, Public Works
❑ Becky Nugent, Public Relations
❑ Julie O'Connell, Human Resources
❑ Mark Smith, Public Works
❑ Ed Spillane, Municipal Judge
❑ Cheryl Turney, Purchasing Mgr.
ationship 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
i Ron Gay, Place 3
❑ Nancy Berry, Place 6
City of College Station Elected Officials
College Station City Council
❑ Ben White, Place I ❑ John Happ, Place 2
❑ Susan Lancaster, Place 4 ❑ Chris Scotti, Place 5
❑ NONE
City of College Station Committees, Boards, and Commissions
❑ Larry Ringer, Chairman
❑ Eric Miller
❑ Lois Koontz
❑ Sarah Adams, Chair
❑ James Batenhorst
❑ David Chester
❑ Dan B. Sears, Chairman
❑ Mike Lane
❑ Steve Parker, alternate
❑ Karen Kasper, Merchant
O Joey Dunn, Dir. Planning & Dev
O NONE
B/CS Library Committee
❑ Katherine Edwards
❑ Jeanne Mitchell
❑ James Bradford
Cemetery Committee
❑ Virginia Reese
❑ Mary Lind Bryan
❑ NONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
❑ George McLean, Vice Chair
❑ Larry D. Patton
❑ David Ruesink, alternate
Facade Improvement Program
Advisory Committee
❑ Don Scherr
❑ Jo Berg
❑ NONE
❑ Kevin Myers
❑ Joe Wallace
❑ Frank Cox
❑ David Hart, alternate
❑ NONE
❑ Valerian Miranda, Architect ❑ Rick Lemmons, Business Owner
❑ Robert Mosley, City Engineer ❑ Eric Barton, CD Coordinator
❑ Hillary Jessup, Chairman
❑ Marguerite Anthony
❑ Thomas Taylor
❑ Colleen Risinger
❑ Rebecca Eplen
❑ Rusleen Maurice
❑ NONE
❑ Kathleen Ireland
❑ Carol Blaschke
❑ John Crompton
❑ NONE
Historic Preservation Committee
❑ Bill Lancaster
❑ David Ruesink
❑ Ernie Wright
❑ NONE
Joint Relief Funding Review
Committee
❑ J. Kevin Byrne
❑ Charlotte Mikulee
Parks and Recreation Board
❑ Glenn Schroeder
❑ Jeannie McCandless
❑ Harry Green
Planning and Zoning
Commission
❑ Scott Shafer, Chairman ❑ John Nichols
❑ Marsha Sanford ❑ Dennis Christiansen
❑ Harold Strong 11 NONE
H
Design Review Board
❑ Rick Hunter eany Goodwin ❑ Nancy Sawtelle
❑ Alan King Ward Wells ❑ Scott Shafer
❑ Susie Cox, alternate ❑ Robert Rayburn, alternate ❑ NONE
❑ Marsha Crenwelge
❑ Dipankar Sen
❑ Neal Nutall, Jr.
❑ Mary Sherwood
❑ Peggy Samson
❑ Jodi Warner
O Gary Thomas
❑ Gary Erwin
❑ Ken Reynolds
❑ Bill Davis
❑ Jay Goss, Chair
❑ Graham Sheffy
❑ Denise Whisenant
Zoning Board of Adjustments
O Joshua Benn
❑ Donald Braune
O Derek Dictson
❑ John Richards
❑ Charles Taylor
O NONE
❑ David Hickson
❑ Glenn Brown, City Manager
❑ Sharon Colson, Chair
❑ Kenny Mallard
Research Valley Partnership
Board of Directors
❑ Larry Mariott
❑ NONE
Wolf Pen Creek TIF Board
❑ Marsha Sanford, Vice Chair
❑ James Massey
❑ Chris Scotti, Councilman
❑ Marc Chaloupka
❑ 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.
❑ Susan Lancaster
❑ Ron Silvia, Mayor
❑ Ron Silvia, Mayor
❑ Susan Lancaster
❑ Ron Silvia, Mayor
Brazos County Health
Department
❑ Nancy Berry ❑ NONE
Brazos Valley Council of
Governments Board of Directors
❑ NONE
B/CS Metropolitan Planning
Organization
❑ NONE
BVCOG TMPA Regional Park
Project Advisory Board
❑ NONE
BVSWMA Policy Advisory
Board
❑ Susan Lancaster El NONE
❑ Ron Silvia
❑ NONE
❑ Nancy Berry
❑ NONE
❑ Nancy Berry
❑ NONE
liRon Gay
'Ron Gay
❑ Linda LaSuit, MPO
❑ Bryan Woods, TxDOT
City Center Committee
❑ Ben White ❑ Nancy Berry
Intergovernmental Committee
❑ Ben White/ ❑ John Happ
Joint City/School
Intergovernmental Committee
❑ Ben White ❑ John Happ
Sister Cities Association
O NONE
Transportation Committee
❑ John Happ
O Dennis Christianson, TTI
❑ NONE
❑ Ken Fogle
❑ Michael Parker, BVCOG
Describe each affiliation or business relationship with an employee checked in Question 4 above:
ro ti Cys -.1 16 ( a.ifebiars of Qie, 1-65Q4ce (6raTos Vaf fey boar -el of Dcred r5.
Adopted 01/13/06
Wolf Pen Creek Oversight
Committee
Ron Gay
Chris Scotti
NONE
•
•
•
Describe each affiliation or business relationship with an employee checked in Question 4 above:
ro ti Cys -.1 16 ( a.ifebiars of Qie, 1-65Q4ce (6raTos Vaf fey boar -el of Dcred r5.
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, 13. 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.
44jo6
Signat& of person doing business with the governmental entity Date
Adopted 01 /1 3/06