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Scotty's House BV Child Advocacy CenterCONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person do ng business with local governmental entity FORM CIQ 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. J Name of person doing business with Icical governmental entity. 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 ar 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 r‘spect to expenditures of money AND describe the affiliation or business relationship. 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. Adopted 11/02/2005 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity FORM CIQ Page 2 Name of local government officer with whom filer has affilitation or business relationship. (Complete this section only if the answer to A, B, or C is YES.) 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. 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. Zi//P6 Signature of person doing business with the governmental entity Date Adopted 11/02(2005 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 ❑ Nancy Berry, Place 6 City of College Station Elected Officials College Station City Council ❑ Ben White, Place I ❑ Susan Lancaster, Place 4 EfeSu/ON E ❑ John Happ. Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions D Larry Ringer, Chairman ❑ Eric Miller ❑ Lois Koontz ❑ Sarah Adams, Chair ❑ Jame Batenhorst O David Chester ❑ Dan B. Sears, Chairman ❑ Mike Lane ❑ Steve Parker, alternate ❑ Karen Kasper, Merchant O Joey Dunn, Dir. Planning & Dev lENONE B/CS Library Committee ❑ Katherine Edwards ❑ Jeanne Mitchell ❑ James Bradford Cemetery Committee ❑ Virginia Reese ❑ Mary Lind Bryan 12'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 0 Valerian Miranda, Architect ❑ Don Scherr ❑ Jo Berg WKON E ❑ Kevin Myers ❑ Joe Wallace ❑ Frank Cox ❑ David Hart, alternate I I—NONE ❑ Rick Lemmons, Business Owner 0 Robert Mosley, City Engineer ❑ Eric Barton, CD Coordinator CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ 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. 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 I 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 O Michael Clancey, Police Chief ❑ Joey Dunn, Planning & Dev ❑ Don Fazzino, Legislative Liason O Kim Foutz, Economic Dev O Connie Hooks, City Secretary ❑ Jeff Kersten, Finance CION E ❑ 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. Describe each affiliation or business relationship with an employee checked in Question 3 above: ❑ David Hickson ❑ Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard Research Valley Partnership Board of Directors ❑ Larry Mariott N'NLa/ONE Wolf Pen Creek TIF Board ❑ Chris Scotti, Councilman ❑ Marsha Sanford, Vice Chair ❑ Marc Chaloupka 0 James Massey 111-11ONE The following individuals are appo nted 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 ❑ Susan Lancaster ❑ Ron Silvia, Mayor ❑ Ron Silvia, Mayor ❑ Susan Lancaster ❑ Ron Silvia, Mayor ❑ Nancy Berry ►td' IV VNE Brazos Valley Council of Governments Board of Directors Id -NONE B/CS Metropolitan Planning Organization ONE BVCOG TMPA Regional Park Project Advisory Board ONE BVSWMA Policy Advisory Board Susan Lancaster /ONE Historic Preservation Committee ❑ Hillary Jessup, Chairman 0 Bill Lancaster ❑ Marguerite Anthony ❑ David Ruesink ❑ Thomas Taylor ❑ Ernie Wright ❑ Colleen Risinger ®-ONE ❑ Rebecca Eplen ❑ Rusleen Maurice IIONE ❑ Kathleen Ireland O Carol Blaschke ❑ John Crompton EKON E Joint Relief Funding Review Committee ❑ J. Kevin Byrne ❑ Charlotte Mikulee Parks and Recreation Board O Glenn Schroeder ❑ Jeannie McCandless ❑ Harry Green Planning and Zoning Commission ❑ Scott Shafer, Chairman 0 John Nichols ❑ Marsha Sanford ❑ Dennis Christiansen O Harold Strong Q E Design Review Board ❑ Marsha Crenwelge ❑ Dipankar Sen ❑ Neal Nutall, Jr. ❑ Mary Sherwood ❑ Peggy Samson ❑ Jodi Warner ❑ Gary Thomas ❑ Gary Erwin ❑ Ken Reynolds ❑ Bill Davis ❑ Rick Heany ❑ Hunter Goodwin ❑ Nancy Sawtelle ❑ Alan King ❑ Ward Wells 0 Scott Shafer'NO O Susie Cox, alternate ❑ Robert Rayburn, alternate ISc�NE Zoning Board of Adjustments ❑ Jay Goss, Chair ❑ Joshua Benn ❑ John Richards ❑ Graham Sheffy 0 Donald Braune 0 Charles Taylor O Denise Whisenant 0 Derek Dictson ONE CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity This section, item 5 including subp has affiliation or other relationship. 5. Name of local government offi this section only if the answer to FORM CIQ s A, B, C & D, must be completed for each officer with whom the filer ttach additional pages to this Form CIQ as necessary. r with whom filer has affiliation or business relationship. (Complete , 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 re•eiving or likely to receive taxable income from or at the direction of the local government officer named in th s section AND the taxable income is not from the local governmental entity? Yes No C. Is the filer of this questionnaire of liated with a corporation or other business entity that the local government officer serves as an offic: r or d -c tor, or holds an ownership of 10 percent or more? Yes No D. Describe each affiliation or busine•s relationship. 6. Signature of person doing business with he governmental entity g0/9 Date Adopted 01/13/06 ❑ Ron Silvia NONE ❑NancyNBerry _ SON E ❑ Nancy Berry ONE City Center Committee 0 Ben White ❑ Nancy Berry Intergovernmental Committee ❑ Ben Whiter ❑ John Happ Joint City/School Intergovernmental Committee ❑ Ben White ❑ John Happ Sister Cities Association ❑ Ron Gay LONE ❑ Ron Gay O Linda LaSuit, MPO ❑ Bryan Woods, TxDOT Transportation Committee ❑ John Happ ❑ Dennis Christianson, TTI C►3'NONE ❑ Ken Fogle O Michael Parker, BVCOG Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06 Wolf Pen Creek Oversight Committee Ron Gay Chris Scotti ONE ■ ■ Describe each affiliation or business relationship with an employee checked in Question 4 above: Adopted 01/13/06