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HomeMy WebLinkAboutEver Ready First AidCONFLICT 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 commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor. OFFICE USE ONLY Date Received Name of person doing business with local governmental entity. weeeP4I)yf()k,) filing authority not later than Code, is pending and incomplete or inaccurate.) 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 September 1 of the year for which an activity described in Section 176.006(a), Local Government not later than the 7th business day after the date the originally filed questionnaire becomes 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. /\ .- 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 governmental entity that is the subject of this questionnaire. V 0 A) F Amended 01/13/2006 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity FORM CIQ Page 2 J 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.) This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or business 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 rill 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. Describe any other affiliation or business relationship that might cause a conflict of interest. Nld Signature of person doing business with the governmental entity Amended 01/13/2006 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. OFFICE USE ONLY Date Received 1. Name of person doing business with local governmental entity. 2. re/4-07 rhes---( 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 ❑ David Massey. Electric ❑ Michael Clancey, Police Chief ❑ Lance Simms, Planning & Dev ❑ John Woody, W/WW ❑ Terry Childers, Asst. City Mgr ❑ Connie Hooks, City Secretary ❑ Jeff Kersten, Chief Fin.Officer ❑ Charles McLemore, Public Works ❑ Becky Nugent, Public Relations ❑ Julie O'Connell, Human Resources ❑ Mark Smith, Asst. City Mgr ❑ 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 ❑ Lynn Mcllhaney, Place 4 ❑ David Ruesink, Place 6 &L. -NONE El John Happ, Place 2 ❑ Chris Scotti, Place 5 City of College Station Committees, Boards, and Commissions ❑ Larry Ringer, Chairman ❑ Eric Miller ❑ Lois Koontz B/CS Library Committee ❑ Katherine Edwards ❑ Jeanne Mitchell ❑ James Bradford Cemetery Committee ❑ Sarah Adams, Chair ❑ Virginia Reese ❑ James Batenhorst ❑ Mary Lind Bryan ❑ David Chester 44141.011E Construction Board of Adjustments and Appeals/Building & Standards Commission ❑ Don Scherr ❑ Jo Berg ❑ Kevin Myers ❑ Joe Wallace ❑ Dan B. Sears, Chairman ❑ George McLean, Vice Chair 0 Frank Cox ❑ Mike Lane ❑ Larry D. Patton 0 David Hart, alternate ❑ Steve Parker, alternate ❑ David Ruesink, alternate LSE 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 NONE ❑ Hillary Jessup, Chairman ❑ Marguerite Anthony ❑ Thomas Taylor ❑ Colleen Risinger Cl Rebecca Eplen CIRusl en Maurice xxv ONE ❑ Kathleen Ireland ❑ Carol Blaschke ❑ J n Crompton irkiNONE ❑ Scott Shafer, Chairman ❑ Marsha Sanford ❑ Harold Strong ❑ Rick Heany ❑ Alan King ❑ Susie Cox, alternate El Jay Goss, Chair ❑ Graham Sheffy ❑ Denise Whisenant Historic Preservation Committee ❑ Bill Lancaster ❑ David Ruesink O Ernie Wright LONE Joint Relief Funding Review Committee ❑ J. Kevin Byrne O Charlotte Mikulee Parks and Recreation Board ❑ Glenn Schroeder ❑ Jeannie McCandless ❑ Harry Green Planning and Zoning Commission ❑ John Nichols ❑ Dennis Christiansen INE Design Review Board ❑ Hunter Goodwin ❑ Ward Wells ❑ Robert Rayburn, alternate Cl Marsha Crenwelge ❑ Dipankar Sen ❑ Neal Nutall, Jr. ❑ Mary Sherwood ❑ Peggy Samson ❑ Jodi Warner ❑ Gary Thomas ❑ Gary Erwin ❑ Ken Reynolds O Bill Davis ❑ Nancy Sawtelle ❑ Scott Shafer Zoning Board of Adjustments ❑ Joshua Benn ❑ John Richards ❑ Donald Braune 0 C h les Taylor O Derek Dictson Q NONE Cl David Hickson Research Valley Partnership Board of Directors ❑ Lam Mariott ❑ Chris Scotti, Councilman ❑ Glenn Brown, City Manager f ]/NONE ❑ Sharon Colson, Chair El Kenny Mallard Wolf Pen Creek TIF Board ❑ Marsha Sanford, Vice Chair ❑ Marc Chaloupka ❑ James Massey 1VNONE 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 AXONE B/CS Metropolitan Planning Organization ❑ Ron Silvia, Mayor pONE BVCOG TMPA Regional Park Project Advisory Board ❑ Susan Lancaster NE BVSWMA Policy Advisory Board 0 Ron Silvia, Mayor 0 Susan Lancaster )i NONE ❑ Ron Silvia 4ONE ❑ Nancy Berry PONE ❑ Nancy Berry ]GONE 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 [TONE ❑ Ron Gay ❑ Linda LaSuit, MPO ❑ Bryan Woods, TxDOT Transportation Committee ❑ John Happ ❑ Dennis Christianson, TTI B. NONE ❑ 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 ❑ Chris ScottiC�}'NONE • Ron Gay 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 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 commits 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 local governmental entity. sJ Eoec F'(m° A 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.) 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. A,/ f 1 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 governmental entity that is the subject of this questionnaire. Amended 01/1312006 CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity FORM CIQ Page 2 J 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.) This section, item 5 including subparts A, B, C & D, must be completed for each officer with whom the filer has affiliation or business 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 0 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 n 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 FOI No D. Describe each affiliation or business relationship. Describe any other affiliation or business relationship that might cause a conflict of interest. ,k/d (,k{qA Signature of person doing business with the governmental entity Amended 01/13/2006