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HomeMy WebLinkAboutMarek Brothers 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. MMeg SW/17 4'1(S Cif ?xUG /WA-) 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. ❑ Glenn Brown, City Manager ❑ Robert Alley, Fire Chief O Pete Caler, Landfill Mgr. ❑ David Gwin, Economic Dev. O David Massey, Electric O Lance Simms, Planning & Dev ❑ Cheryl Turney, Purchasing Mgr. ❑ Terry Childers, Deputy City Mgr O Steve Beachy, Parks & Rec ❑ Harvey Cargill, City Attorney ❑ Connie Hooks, City Secretary O Becky Nugent, Public Relations ❑ Mark Smith, Public Works O 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 L'NONE 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 0 Lynn Mcllhaney, Place 4 O David Ruesink, Place 6 P( NONE ❑ John Happ, Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions B/CS Library Committee ❑ Larry Ringer, Chairman ❑ Katherine Edwards ❑ Don Scherr O Mary Fran Troy 0 Jeanne Mitchell ❑ B. Carroll Johnson ❑ Sonio Margarita Gangotena ❑ James Bradford '� NONE Cemetery Committee ❑ Sarah Adams, Chair 0 Virginia Reese ❑ James Batenhorst 0 Weldon Kruger ❑ David Chester 0 RC Slocum ❑ Donald Braune 1 NONE ❑ Dan B. Sears, Chairman ❑ Mike Lane O Steve Parker, alternate IRJ NONE Construction Board of Adjustments and Appeals/Building & Standards Commission ❑ Frank Cox ❑ Larry D. Patton ❑ Glenn Thomas, alternate ❑ Kevin Myers ❑ Joe Wallace ❑ James Matson ❑ David Hart ❑ Charles Thomas, alternate ❑ Quinn Williams ❑ Hillary Jessup, Chairman ❑ Haskell Monroe ❑ Ernie Wright i, NONE Historic Preservation Committee ❑ Bill Lancaster ❑ Jane Hughey ❑ Neal Nutall, Jr. Joint Relief Funding Review Committee ❑ Marguerite Anthony ❑ Meredith Waller O Colleen Risinger ❑ Tedi Ellison ❑ J. Kevin Byrne ❑ Deborah Deitering ❑ Rusleen Maurice 0 Reba Ragdale 0 1, NONE ❑ Jodi Warner, Chair ❑ Shawn Rhodes ❑ John Crompton ,NONE Parks and Recreation Board ❑ Kathleen Ireland ❑ Jody Ford ❑ Harry Green Planning and Zoning Commission ❑ John Nichols, Chair ❑ Glenn Schroeder ❑ Marsha Sanford ❑ Dennis Christiansen ❑ Harold Strong `Ft NONE Design Review Board ❑ Joan Perry ❑ Gary Thomas O Gary Erwin ❑ Derek Dictson ❑ Bill Davis ❑ Rick Heaney ❑ Hunter Goodwin ❑ Nancy Sawtelle ❑ Alan King ❑ Ward Wells 0 John Nichols ❑ Susie Cox, alternate ❑ Robert Raybum, alternate yl NONE ❑ Jay Goss, Chair ❑ Denise Whisenant F. NONE Zoning Board of Adjustments ❑ Joshua Benn ❑ Donald Braune ❑ John Richards ❑ Thomas Mather ❑ Larry Hodges ❑ Glenn Brown, City Manager O Sharon Colson, Chair O Kenny Mallard Research Valley Partnership Board of Directors ❑ Larry Mariott Tig. NONE Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair O James Massey Outside Agency Funding Review ❑ Don Lewis ❑ Charles Taylor ❑ Gregg Baird ❑ Sheryl Welford ❑ Chad Jones , NONE ❑ Stephen Syptak, Chair ❑ Tom fit'. NONE ❑ Hugh Lindsay, Area I ❑ John Crompton, Area II ❑ Steve Arden, Area IIl ❑ Hugh Stearns, Area IV O Andrew Burleson, Student Resident ❑ Dorthea Robinson, Alternate, ETJ Resident O Chris Scotti, Councilmember ❑ Hillary Jessup, Historic Preservation ❑ Lloyd Wasserman, County Commission Northgate Tax Increment Finance Board O David Scarmardo O Glenn Thomas Comprehensive Plan Committee ❑ John Richards, Area I ❑ Brian Bochner, Area II O 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 NONE ❑ Roger Reese ❑ Carolyn Berrow ❑ Anne Jackson ❑ Dale O'Reiley ❑ David Hart, Alternate, Area I ❑ Dennis Corrington, Alternate, Area H ❑ Tom Taylor, Alternate, Area III ❑ 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 O James Massey, Intergovernmental Comm/TAMU Admin O Dr. Clark Ealy, Intergovernmental Comm/C SI SD ❑ Chuck Martinez, Intergovernmental Comm/ Research Valley Patnership ❑ Linda LaSut, Intergovernmental Comm/MPO ❑ Lindsey Guindi, Intergovernmental Comm/Chamber of Commerce ❑ Rodney Weis, Intergovernmental Comm/TAMU Transit ❑ Dr. Colleen Netterville, Intergovernmental Comm/BISD ❑ Margie Lucas, Intergovernmental Comm/ Brazos Transit District ❑ Chad Bohne, Intergovernmental Comm/TxDOT ❑ Michael Parks, Intergovernmental Comm/BVCOG ❑ Gary Arnold, Intergovernmental Comm/Brazos County Sheriff ❑ Gary Teston, Intergovernmental Comm/ Easterwood Airport 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 WhiteNONE Brazos Valley Council of Governments ❑ Ron Silvia, Mayor IF. NONE B/CS Metropolitan Planning Organization ❑ Ron Silvia, Mayor NONE BVCOG TMPA Regional Park Project Advisory Board O Lynn Mcllhaney tjEt, NONE BVSWMA Policy Advisory Board O Ron Silvia, Mayor ❑ Chris Scotti NONE City Center Committee ❑ Ron Silvia ❑ Ben White ❑ Dave Ruesink p. NONE Intergovernmental Committee ❑ Ron Gay 0 Ben White ❑ John Happ 'f NONE ❑ Dave Ruesink cg, NONE Joint City/School Intergovernmental Committee ❑ Ben White ❑ John Happ Sister Cities Association O Dave Ruesink 1 NONE Transportation Committee ❑ Ron Gay ❑ John Happ 0 Lynn Mcllhane_y ❑ Ken Fogle ❑ Linda LaSuit, MPO ❑ Dennis Christianson, TTI ❑ Michael Parker, BVCOG 0 Bryan Woods, TxDOT 'fad' NONE Wolf Pen Creek Oversight Committee ❑ Ron Gay 0 Chris Scotti ❑ Marc Chaloupka O John Nichols 0 Marsha Sanford ❑ Jodi Warner ❑ Joan Perry 0 Sharon Colson 1?, 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 1 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. Si ature of person doing business with the goverr►an ;inti 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. 2. Marek Brothers Const., Inc FORM CIQ OFFICE USE ONLY Date Received CO - Y 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 ❑ Charles Wood, Economic Dev ❑ Connie Hooks, City Secretary ❑ Jeff Kersten, Finance 127NONE ❑ 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: 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 ❑ Susan Lancaster, Place 4 ❑ Nancy Berry, Place 6 C NONE ❑ John Happ, Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions B/CS Library Committee ❑ Larry Ringer, Chairman ❑ Katherine Edwards ❑ Don Scherr ❑ Eric Miller ❑ Jeanne Mitchell ❑ Jo Berg ❑ Lois Koontz ❑ James Bradford E2 NONE Cemetery Committee ❑ Sarah Adams, Chair ❑ Virginia Reese ❑ James Batenhorst ❑ Mary Lind Bryan ❑ David Chester DVN. ONE Construction Board of Adjustments and Appeals/Building & Standards Commission ❑ Kevin Myers ❑ Joe Wallace ❑ Dan B. Sears, Chairman ❑ George McLean, Vice Chair ❑ Frank Cox ❑ Mike Lane ❑ Larry D. Patton ❑ David Hart, alternate ❑ Steve Parker, alternate ❑ David Ruesink, alternate lEt ZONE ❑ Karen Kasper, Merchant ❑ Joey Dunn, Dir. Planning & Dev VNONE Facade Improvement Program Advisory Committee ❑ 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 2 NONE ❑ Kathleen Ireland ❑ Carol Blaschke ❑ John Crompton lE NONE ❑ Scott Shafer, Chairman ❑ Marsha Sanford ❑ Harold Strong ❑ Rick Heany ❑ Alan King ❑ Susie Cox, alternate ❑ Jay Goss, Chair ❑ Graham Sheffy ❑ Denise Whisenant Historic Preservation Committee ❑ Bill Lancaster Cl 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 ❑ John Nichols ❑ Dennis Christiansen l'NONE Design Review Board ❑ Hunter Goodwin ❑ Ward Wells ❑ Robert Rayburn, alternate Zoning Board of Adjustments ❑ Joshua Benn ❑ Donald Braune ❑ Derek Dictson ❑ Marsha Crenwelge ❑ Dipankar Sen ❑ Neal Nutall, Jr. ❑ Mary Sherwood ❑ Peggy Samson ❑ Jodi Warner Cl Gary Thomas ❑ Gary Erwin ❑ Ken Reynolds ❑ Bill Davis ❑ Nancy Sawtelle ❑ Scott Shafer L�f 1V ONE ❑ John Richards ❑ Charles Taylor 2- ONE ❑ David Hickson ❑ Glenn Brown, City Manager ❑ Sharon Colson, Chair ❑ Kenny Mallard Research Valley Partnership Board of Directors ❑ Larry Mariott ( v'ONE Wolf Pen Creek TIF Board ❑ Chris Scotti, Councilman ❑ Marsha Sanford, Vice Chair ❑ Marc Chaloupka ❑ James Massey SONE 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 ❑ Susan Lancaster ❑ Nancy Berry ZONE Brazos Valley Council of Governments Board of Directors ❑ Ron Silvia, Mayor C ONE B/CS Metropolitan Planning Organization ❑ Ron Silvia, Mayor 261ONE BVCOG TMPA Regional Park Project Advisory Board ❑ Susan Lancaster 12'KONE BVSWMA Policy Advisory Board 0 Ron Silvia, Mayor 0 Susan Lancaster GONE ❑ Ron Silvia NONE ❑ Nancy Berry 14TONE ❑ Nancy Berry NONE 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 ❑ Ron Gay [ 1 ONE ❑ Ron Gay ❑ Linda LaSuit, MPO ❑ Bryan Woods, TxDOT Transportation Committee ❑ John Happ ❑ Dennis Christianson, TTI ❑'ONE ❑ Ken Fogle ❑ 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 GONE ■ ■ 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. r' A2/iJ son 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. FORM CIQ OFFICE USE ONLY Date Received 1. Name of person doing business with local governmental entity. ,AyLkLeic Mid 1/2440.4,1-, 2. 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 NONE ❑ 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: 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 t ❑ Ron Gay. Place 3 0 Susan Lancaster. Place 4 ❑ Nancy Berry, Place 6 NONE City of College Station Committees, Boards, and Commissions ❑ John Happ, Place 2 O Chris Scotti, Place 5 ❑ Lam Ringer, Chairman ❑ Eric Miller ❑ Lois Koontz B/CS Library Committee ❑ Katherine Edwards ❑ Jeanne Mitchell ❑ James Bradford Cemetery Committee ❑ Sarah Adams, Chair 0 Virginia Reese O James Batenhorst 0 Mary Lind Bryan ❑ David Chester -fp, NONE Construction Board of Adjustments and Appeals/Building & Standards Commission O Don Schen O Jo Berg '59, NONE ❑ Kevin Myers ❑ Joe Wallace ❑ Dan B. Sears, Chairman 0 George McLean, Vice Chair 0 Frank Cox ❑ Mike Lane 0 Larry D. Patton 0 David Hart. alternate ❑ Steve Parker, alternate 0 David Ruesink, alternate IS, NONE Facade Improvement Program Advisory Committee ❑ Karen Kasper, Merchant 0 Valerian Miranda, Architect ❑ Rick Lemmons, Business Owner O Joey Dunn, Dir. Planning & Dev 0 Robert Mosley, City Engineer ❑ Eric Barton, CD Coordinator IkkNONE ❑ Hillary Jessup, Chairman ❑ Marguerite Anthony ❑ Thomas Taylor ❑ Colleen Ri singer ❑ Rebecca Eplen ❑ Rusleen Maurice IA NONE ❑ Kathleen Ireland ❑ Carol Blaschke ❑ John Crompton 711 NONE ❑ Scott Shafer, Chairman ❑ Marsha Sanford ❑ Harold Strong ❑ Rick Heany ❑ Alan King ❑ Susie Cox, alternate ❑ Jay Goss, Chair ❑ Graham Sheffy ❑ Denise Whisenant 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 O Jeannie McCandless ❑ Harry Green Planning and Zoning Commission ❑ John Nichols ❑ Dennis Christiansen NONE Design Review Board ❑ Hunter Goodwin ❑ Ward Wells ❑ Robert Rayburn, alternate Zoning Board of Adjustments ❑ Joshua Berm O Donald Braune ❑ Derek Dictson ❑ Marsha Crenwelge El Dipankar Sen ❑ Neal Nutall, Jr. ❑ Mary Sherwood ❑ Peggy Samson ❑ Jodi Warner ❑ Gary Thomas ❑ Gary Erwin ❑ Ken Reynolds ❑ Bill Davis ❑ Nancy Sawtelle ❑ Scott Shafer NONE ❑ John Richards ❑ Charles Taylor pc NONE Research Valley Partnership Board of Directors ❑ David Hickson 0 Larry Mariott ❑ Glenn Brown, City Manager ¥ONE O Sharon Colson, Chair O Kenny Mallard Wolf Pen Creek TIF Board 0 Chris Scotti, Councilman ❑ Marsha Sanford, Vice Chair 0 Marc Chaloupka ❑ James Massey 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 Susan Lancaster 0 Nancy Berry 'NONE Brazos Valley Council of Governments Board of Directors O Ron Silvia, Mayor tit.NONE B/CS Metropolitan Planning Organization O Ron Silvia, Mayor r NONE BVCOG TMPA Regional Park Project Advisory Board O Susan Lancaster [NONE BVSWMA Policy Advisory Board O Ron Silvia, Mayor 0 Susan Lancaster KNONE ❑ Ron Silvia ( NONE ❑ Nancy Berry 1 NONE ❑ Nancy Berry yi NONE City Center Committee ❑ Ben White ❑ Nancy Berry Intergovernmental Committee O Ben White 0 John Happ Joint City/School Intergovernmental Committee O Ben White 0 John Happ Sister Cities Association ❑ Ron Gay NONE Transportation Committee ❑ Ron Gay ❑ John Happ O Linda LaSuit, MPO 0 Dennis Christianson, TTI O Bryan Woods, TxDOT NONE ❑ Ken Fogle ❑ Michael Parker, BVCOG Wolf Pen Creek Oversight Committee O Ron Gay 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. ,� �%idI Si ture of person doing business with the governmental entity Date Adopted 01/13/06