HomeMy WebLinkAboutKnife RiverCONFLICT 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.
FORM CIQ
OFFICE USE ONLY
Date Received
SEP 202007
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
❑ Pete Caler, Landfill Mgr.
❑ David Gwin, Economic Dev.
❑ David Massey, Electric
❑ Bob Cowell, Planning & Dev
❑ Cheryl Turney, Purchasing Mgr.
❑ Terry Childers, Deputy City Mgr
❑ Steve Beachy, Parks & Rec
❑ Harvey Cargill, City Attorney
❑ Connie Hooks, City Secretary
❑ Becky Nugent, Public Relations
❑ Mark Smith, Public Works
❑ Dave Coleman, W/WW
❑ Kathy Merrill, Asst. City Mgr.
❑ Ben Roper, Inf. Tech.
❑ Michael Clancey, Police Chief
❑ Jeff Kersten, Chief Fin.Officer
❑ Julie O'Connell, Human Resources
❑ Ed Spillane, Municipal Judge
,ZIONE
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
❑ Ben White, Mayor 0 John Compton, Place 1
❑ Ron Gay, Place 3 0 Lynn Mcllhaney, Place 4
❑ David Ruesink, Place 6 NONE
❑ James Massey, Place 2
O Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
O Larry Ringer, Chairman
O Mary Fran Troy
O Sonio Margarita Gangotena
O Sarah Adams, Chair
O James Batenhorst
O David Chester
O Donald Braune
O Dan B. Sears, Chairman
O Mike Lane
O Steve Parker, alternate
O NONE
B/CS Library Committee
❑ Katherine Edwards
❑ Jeanne Mitchell
O James Bradford
Cemetery Committee
O Virginia Reese
O Weldon Kruger
❑ RC Slocum
OKNONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
O Frank Cox
❑ Larry D. Patton
❑ Glenn Thomas, alternate
O Don Scherr
O B. Carroll Johnson
STONE
❑ Kevin Myers
❑ Joe Wallace
O James Matson
O David Hart
O Charles Thomas, alternate
A2NQuinn Williams
❑ Hillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
(NONE
Historic Preservation Committee
❑ Bill Lancaster
❑ Jane Hughey
O Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ Marguerite Anthony
❑ Meredith Waller
❑ Colleen Risinger
❑ Tedi Ellison ❑ J. Kevin Byrne ❑ Deborah Deitering
❑ Rusleen Maurice ❑ Reba Ragdale ❑
ZONE
❑ Jodi Warner, Chair
❑ Shawn Rhodes
❑ John Crompton
NONE
Parks and Recreation Board
❑ Kathleen Ireland
❑ Jody Ford
O Harry Green
Planning and Zoning
Commission
❑ John Nichols, Chair ❑ Glenn Schroeder
❑ Marsha Sanford ❑ Dennis Christiansen
❑ Harold Strong
Design Review Board
❑ Joan Perry
❑ Gary Thomas
❑ Gary Erwin
❑ Derek Dictson
O Bill Davis
❑ Rick Heaney ❑ Hunter Goodwin ❑ Nancy Sawtelle
❑ Alan King ❑ Ward Wells ❑ John Nichols
❑ Susie Cox, alternate ❑ Robert Rayburn, alternate k NONE
❑ Jay Goss, Chair
❑ Denise Whisenant
MNONE
Zoning Board of Adjustments
❑ Joshua Benn
❑ Donald Braune
O John Richards
❑ Thomas Mather
O Larry Hodges
O Glenn Brown, City Manager
0 Sharon Colson, Chair
O Kenny Mallard
CI Don Lewis
O Gregg Baird
O Chad Jones
O Stephen Syptak, Chair
0 Tom Kirkland
baN ONE
O Hugh Lindsay, Area I
O John Crompton, Area II
O Steve Arden, Area III
O Hugh Stearns, Area IV
O Andrew Burleson, Student Resident
O Dorthea Robinson, Alternate,
ETJ Resident
O Chris Scotti, Councilmember
O Hillary Jessup, Historic
Preservation
O Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
O Larry Mariott
akl•IONE
Wolf Pen Creek TIF Board
O Marsha Sanford, Vice Chair
O James Massey
Outside Agency Funding Review
O Charles Taylor
o Sheryl Welford
.11cTONE
Northgate Tax Increment
Finance Board
O David Scarmardo
O Glenn Thomas
Comprehensive Plan Committee
O John Richards, Area I
O Brian Bochner, Area II
O Laurie Corbelli, Area HI
O Jerry Cooper, Area IV
o Kristina Campbell, Alternate,
Student Resident
O Craig Hall, Resident -At -Large
O Lynn Mcllhaney, Alternate,
Councilmember
O Gary Erwin, Parks & Rec
O Larry Haskins, Northgate
District Assoc.
O Chris Scotti, Councilman
O Marc Chaloupka
NONE
O Roger Reese
0 Carolyn Berrow
O Anne Jackson
O Dale O'Reiley
O David Hart, Alternate, Area I
O Dennis Corrington, Alternate, Area II
O Tom Taylor, Alternate, Area III
O Adrian Williams, Alternate, Area IV
0 Douglas Rape', ETJ Resident
O Mike Guido, Alternate,
Resident -At -Large
O Bill Davis, P&Z
O Kathleen Ireland, Parks & Rec
Alternate
O Bo Miles, Building & Land
Development
❑ Larry Marriott, Home Builders
Assoc.
El Tedi Ellison, Intergovernmental
Comm/Chamber of Commerce
❑ James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
El 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
El Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
CommBVCOG
❑ Gary Arnold, Intergovernmental
Comm/Brazos County Sheriff
❑ Gary Teston, Intergovernmental
kNONE
Comm/ Easterwood Airport
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.
❑ Lynn Mcllhaney
❑ Mayor
❑ Mayor
❑ Lynn Mcllhaney
❑ Mayor
❑ Ron Silvia
NONE
❑ Ron Gay
bltl,NONE
Brazos County Health
Department
❑ Ben White LliONE
Brazos Valley Council of
Governments
ilZ(NONE
B/CS Metropolitan Planning
Organization
NONE
BVCOG TMPA Regional Park
Project Advisory Board
lc
BVSWMA Policy Advisory
Board
❑ Chris Scotti
City Center Committee
❑ Ben White
Intergovernmental Committee
❑ Ben White
pcZL_NONE
❑ Dave Ruesink
❑ John Happ
O Dave Ruesink
p‘NONE
Joint City/School
Intergovernmental Committee
0 Ben White
Sister Cities Association
O Dave Ruesink ONE
Transportation Committee
0 John Happ
O Ron Gay 0 John Happ 0 Lynn McIlhaney
O Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI
0 Michael Parker, BVCOG 0 Bryan Woods, TxDOT N._NONE
O Ron Gay
O John Nichols
O Joan Perry
Wolf Pen Creek Oversight
Committee
O Chris Scotti
O Marsha Sanford
O Sharon Colson
O Marc Chaloupka
O Jodi Warner
WKONE
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 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.
(„00; vtvn W I ) I CaP1/4 5
A. Is the local government officer named in this section receiving or likely to receive taxable income from the
filer of the questionnaire?
Yes
Mt . (c): 1\4w 5 ►5 ewlT eJ L7
No -4VQ/
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 M 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.
Signa
ure of
erson doing business with the governmental entity
Date
Adopted 01/13/06
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
OFFICE USE ONLY
Government Code by a person doing business with the governmental entity. Date Received
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 bksiness with local governmental entity.
(.\‘
2.
JeX
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
❑ Pete Caler, Landfill Mgr.
O David Gwin, Economic Dev.
❑ David Massey, Electric
❑ Bob Cowell, Planning & Dev
❑ Cheryl Turney, Purchasing Mgr.
O Terry Childers, Deputy City Mgr
❑ Steve Beachy, Parks & Rec
❑ Harvey Cargill, City Attorney
❑ Connie Hooks, City Secretary
O Becky Nugent, Public Relations
❑ Mark Smith, Public Works
❑ John Woody, W/WW
❑ Kathy Merrill, Asst. City Mgr.
O Ben Roper, Inf. Tech.
❑ Michael Clancey, Police Chief
❑ Jeff Kersten, Chief Fin.Officer
O Julie O'Connell, Human Resources
❑ Ed Spillane, Municipal Judge
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.
❑ Ben White, Mayor
❑ Ron Gay, Place 3
❑ David Ruesink, Place 6
City of College Station Elected Officials
College Station City Council
❑ OPEN, Place 1
❑ Lynn McIlhaney, Place 4
NONE
❑ James Massey, Place 2
❑ Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
❑ Larry Ringer, Chairman
❑ Mary Fran Troy
❑ Sonio Margarita Gangotena
❑ Sarah Adams, Chair
❑ James Batenhorst
❑ David Chester
O Donald Braune
❑ Dan B. Sears, Chairman
❑ Mike Lane
❑ Steve Parker, alternate
O NONE
B/CS Library Committee
❑ Katherine Edwards 0 Don Schen
❑ Jeanne Mitchell 0 B. Carroll Johnson
❑ James Bradford (NONE
Cemetery Committee
❑ Virginia Reese
❑ Weldon Kruger
❑ RC Slocum
KNONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
❑ Frank Cox
❑ Larry D. Patton
❑ Glenn Thomas, alternate
❑ Kevin Myers
❑ Joe Wallace
O James Matson
❑ David Hart
❑ Charles Thomas, alternate
L74uinn Williams
❑ Hillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
X NONE
❑ Tedi Ellison
❑ Rusleen Maurice
NONE
❑ Jodi Warner, Chair
❑ Shawn Rhodes
❑ John Crompton
NONE
O John Nichols, Chair
❑ Marsha Sanford
O Harold Strong
❑ Rick Heaney
❑ Alan King
❑ Susie Cox, alternate
❑ Jay Goss, Chair
❑ Denise Whisenant
NONE
Historic Preservation Committee
❑ Bill Lancaster
❑ Jane Hughey
❑ Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ J. Kevin Byrne
❑ Reba Ragdale
Parks and Recreation Board
❑ Kathleen Ireland
❑ Jody Ford
❑ Harry Green
Planning and Zoning
Commission
O Glenn Schroeder
❑ Dennis Christiansen
NONE
Design Review Board
❑ Marguerite Anthony
❑ Meredith Waller
❑ Colleen Risinger
❑ Deborah Deitering
0
❑ Joan Perry
❑ Gary Thomas
❑ Gary Erwin
❑ Derek Dictson
❑ Bill Davis
❑ Hunter Goodwin ❑ Nancy Sawtelle
❑ Ward Wells ❑ John Nichols
O Robert Rayburn, alternate NONE
Zoning Board of Adjustments
❑ Joshua Benn
O Donald Braune
❑ John Richards
O Thomas Mather
❑ Larry Hodges
O Glenn Brown, City Manager
❑ Sharon Colson, Chair
❑ Kenny Mallard
❑ Don Lewis
❑ Gregg Baird
❑ Chad Jones
❑ Stephen Syptak, Chair
O Tom Kirkland
/^NONE
❑ Hugh Lindsay, Area I
❑ John Crompton, Area II
❑ Steve Arden, Area III
❑ Hugh Stearns, Area IV
❑ Andrew Burleson, Student Resident
❑ Dorthea Robinson, Alternate,
ETJ Resident
❑ Chris Scotti, Councilmember
❑ Hillary Jessup, Historic
Preservation
❑ Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
El Larry Mariott
pl. NONE
Wolf Pen Creek TIF Board
❑ Marsha Sanford, Vice Chair
❑ James Massey
Outside Agency Funding Review
❑ Charles Taylor
❑ Sheryl Welford
c1ONE
Northgate Tax Increment
Finance Board
❑ David Scarmardo
❑ Glenn Thomas
Comprehensive Plan Committee
❑ John Richards, Area I
❑ Brian Bochner, Area II
❑ 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
O Anne Jackson
❑ Dale O'Reiley
❑ David Hart, Alternate, Area I
❑ Dennis Corrington, Alternate, Area II
❑ 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
O Bo Miles, Building & Land
Development
❑ Larry Marriott, Home Builders
Assoc.
O Tedi Ellison, Intergovernmental
Comm/Chamber of Commerce
O James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
O Linda LaSut, Intergovernmental
Comm/MPO
❑ Lindsey Guindi, Intergovernmental
Comm/Chamber of Commerce
❑ Rodney Weis, Intergovernmental
Comm/TAMU Transit
O Dr. Colleen Netterville,
Intergovernmental CommBISD
❑ Margie Lucas,
Intergovernmental Comm/
Brazos Transit District
❑ Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
CommBVCOG
O 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
❑ Lynn Mcllhaney ❑ Ben White NONE
Brazos Valley Council of
Governments
❑ Mayor pQ NONE
B/CS Metropolitan Planning
Organization
O Mayor CkNONE
BVCOG TMPA Regional Park
Project Advisory Board
❑ Lynn Mcllhaney NONE
BVSWMA Policy Advisory
Board
0 Mayor ❑ Chris Scotti gkNONE
City Center Committee
❑ Ron Silvia 0 Ben White 0 Dave Ruesink
t9LNONE
Intergovernmental Committee
❑ Ron Gay ❑ Ben White 0 John Happ
NONE
❑ Dave Ruesink
65KNONE
Joint City/School
Intergovernmental Committee
❑ Ben White ❑ John Happ
Sister Cities Association
❑ Dave Ruesink /LNONE
Transportation Committee
❑ Ron Gay 0 John Happ 0 Lynn Mcllhaney
O Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI
O Michael Parker, BVCOG ❑ Bryan Woods, TxDOT NONE
❑ Ron Gay
❑ John Nichols
❑ Joan Perry
Wolf Pen Creek Oversight
Committee
❑ Chris Scotti
❑ Marsha Sanford
❑ Sharon Colson
❑ Marc Chaloupka
❑ Jodi Warner
NONE
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 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
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.
kif. cu X11 io,,.s ;s evielleyod
Signa ire of person 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.
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.
❑ Glenn Brown, City Manager
❑ Robert Alley, Fire Chief
❑ Pete Caler, Landfill Mgr.
❑ David Gwin, Economic Dev.
❑ David Massey, Electric
❑ Bob Cowell, Planning & Dev
❑ Cheryl Turney, Purchasing Mgr.
❑ Terry Childers, Deputy City Mgr
❑ Steve Beachy, Parks & Rec
❑ Harvey Cargill, City Attorney
❑ Connie Hooks, City Secretary
❑ Becky Nugent, Public Relations
❑ Mark Smith, Public Works
❑ John Woody, W/WW
❑ Kathy Merrill, Asst. City Mgr.
❑ Ben Roper, Inf. Tech.
❑ Michael Clancey, Police Chief
❑ Jeff Kersten, Chief Fin.Officer
❑ Julie O'Connell, Human Resources
❑ Ed Spillane, Municipal Judge
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.
❑ Ben White, Mayor
❑ Ron Gay, Place 3 ❑ Lynn Mcllhaney, Place 4 ❑ Chris Scotti, Place 5
❑ David Ruesink, Place 6 NONE
City of College Station Elected Officials
College Station City Council
❑ OPEN, Place 1
❑ James Massey, Place 2
City of College Station Committees, Boards, and Commissions
B/CS Library Committee
❑ Katherine Edwards
❑ Larry Ringer, Chairman
❑ Mary Fran Troy
❑ Sonio Margarita Gangotena
❑ Sarah Adams, Chair
❑ James Batenhorst
❑ David Chester
O Donald Braune
❑ Dan B. Sears, Chairman
O Mike Lane
❑ Steve Parker, alternate
O NONE
❑ Jeanne Mitchell
❑ James Bradford
Cemetery Committee
❑ Virginia Reese
❑ Weldon Kruger
❑ RC Slocum
‘;,14NONE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
❑ Frank Cox
❑ Larry D. Patton
❑ Glenn Thomas, alternate
❑ Don Scherr
❑ B. Carroll Johnson
NONE
❑ Kevin Myers
❑ Joe Wallace
❑ James Matson
❑ David Hart
❑ Charles Thomas, alternate
Quinn Williams
❑ Hillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
Dig -NONE
Historic Preservation Committee
❑ Bill Lancaster
❑ Jane Hughey
Cl Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ Marguerite Anthony
❑ Meredith Waller
❑ Colleen Risinger
❑ Tedi Ellison ❑ J. Kevin Byrne ❑ Deborah Deitering
❑ Rusleen Maurice Cl Reba Ragdale ❑
-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 (NONE
Design Review Board
❑ Joan Perry
❑ Gary Thomas
❑ Gary Erwin
❑ Derek Dictson
❑ Bill Davis
❑ Rick Heaney ❑ Hunter Goodwin ❑ Nancy Sawtelle
❑ Alan King ❑ Ward Wells ❑ John Nichols
❑ Susie Cox, alternate ❑ Robert Rayburn, alternate NONE
❑ Jay Goss, Chair
❑ Denise Whisenant
NONE
Zoning Board of Adjustments
❑ Joshua Benn
❑ Donald Braune
Cl John Richards
❑ Thomas Mather
❑ Larry Hodges
❑ Glenn Brown, City Manager
❑ Sharon Colson, Chair
❑ Kenny Mallard
❑ Don Lewis
❑ Gregg Baird
❑ Chad Jones
❑ Stephen Syptak, Chair
❑ Tom Kirkland
kNONE
❑ Hugh Lindsay, Area I
❑ John Crompton, Area II
❑ Steve Arden, Area III
❑ Hugh Stearns, Area IV
❑ Andrew Burleson, Student Resident
❑ Dorthea Robinson, Alternate,
ETJ Resident
❑ Chris Scotti, Councilmember
❑ Hillary Jessup, Historic
Preservation
❑ Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
❑ Larry Mariott
NONE
Wolf Pen Creek TIF Board
❑ Marsha Sanford, Vice Chair
❑ James Massey
Outside Agency Funding Review
❑ Charles Taylor
❑ Sheryl Welford
cK NONE
Northgate Tax Increment
Finance Board
❑ David Scarmardo
❑ Glenn Thomas
Comprehensive Plan Committee
❑ John Richards, Area I
❑ Brian Bochner, Area II
❑ 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
ONE
❑ Roger Reese
❑ Carolyn Berrow
❑ Anne Jackson
❑ Dale O'Reiley
❑ David Hart, Alternate, Area I
❑ Dennis Corrington, Alternate, Area 11
❑ Tom Taylor, Alternate, Area III
❑ Adrian Williams, Alternate, Area TV
❑ 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
❑ James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ Chuck Martinez,
Intergovernmental Comm/
Research Valley Patnership
❑ Linda LaSut, Intergovernmental
Comm/MPO
O Lindsey Guindi, Intergovernmental
Comm/Chamber of Commerce
❑ Rodney Weis, Intergovernmental
Comm/TAMU Transit
O Dr. Colleen Netterville,
Intergovernmental Comm/BISD
O Margie Lucas,
Intergovernmental Comm/
Brazos Transit District
❑ Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
Comm/B VCOG
❑ Gary Arnold, Intergovernmental
Comm/Brazos County Sheriff
❑ Gary Teston, Intergovernmental
Comm/ Easterwood Airport
cW.LNIONE
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
❑ Lynn Mcllhaney ❑ Ben White ( ONE
Brazos Valley Council of
Governments
❑ Mayor NONE
B/CS Metropolitan Planning
Organization
❑ Mayor N.AONE
BVCOG TMPA Regional Park
Project Advisory Board
❑ Lynn Mcllhaney 1C NONE
BVSWMA Policy Advisory
Board
❑ Mayor ❑ Chris Scotti ONE
City Center Committee
❑ Ron Silvia ❑ Ben White ❑ Dave Ruesink
NONE
Intergovernmental Committee
❑ Ron Gay ❑ Ben White ❑ John Happ
NONE
❑ Dave Ruesink
MNONE
Joint City/School
Intergovernmental Committee
❑ Ben White ❑ John Happ
Sister Cities Association
❑ Dave Ruesink NONE
Transportation Committee
❑ Ron Gay ❑ John Happ ❑ Lynn Mcllhaney
❑ Ken Fogle ❑ Linda LaSuit, MPO ❑ Dennis Christianson, TTI
❑ Michael Parker, BVCOG ❑ Bryan Woods, TxDOT IIS<ONE
❑ Ron Gay
❑ John Nichols
❑ Joan Perry
Wolf Pen Creek Oversight
Committee
❑ Chris Scotti
❑ Marsha Sanford
❑ Sharon Colson
❑ Marc Chaloupka
❑ Jodi Warner
C 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?
V
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.
04); LU MCOAA Ls ewylord
6.
Signature of
erson
oing 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.
KK; fe (e ver
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.
❑ Glenn Brown, City Manager ❑ Terry Childers, Deputy City Mgr ❑ Kathy Merrill, Asst. City Mgr.
❑ Robert Alley, Fire Chief ❑ Steve Beachy, Parks & Rec ❑ Olivia Burnside, Inf. Tech.
❑ Pete Caler, Landfill Mgr. ❑ Harvey Cargill, City Attorney ❑ Michael Clancey, Police Chief
❑ David Gwin, Economic Dev. ❑ Connie Hooks, City Secretary 0 Jeff Kersten, Chief Fin.Officer
❑ David Massey, Electric ❑ Becky Nugent, Public Relations 0 Julie O'Connell, Human Resources
❑ Lance Simms, Planning & Dev ❑ Mark Smith, Public Works 0 Ed Spillane, Municipal Judge
❑ Cheryl Turney, Purchasing Mgr. 0 John Woody, W/WWNONE
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.
❑ Ron Silvia, Mayor
❑ Ron Gay, Place 3
❑ David Ruesink, Place 6
City of College Station Elected Officials
College Station City Council
❑ Ben White, Place 1
❑ Lynn McIlhaney, Place 4
NONE
❑ John Happ, Place 2
❑ Chris Scotti, Place 5
City of College Station Committees, Boards, and Commissions
❑ Larry Ringer, Chairman
❑ Mary Fran Troy
❑ Sonio Margarita Gangotena
❑ Sarah Adams, Chair
❑ James Batenhorst
❑ David Chester
❑ Donald Braune
❑ Dan B. Sears, Chairman
❑ Mike Lane
❑ Steve Parker, alternate
❑ NONE
B/CS Library Committee
❑ Katherine Edwards
❑ Jeanne Mitchell
❑ James Bradford
Cemetery Committee
❑ Virginia Reese
❑ Weldon Kruger
El RC Slocum
bl<1\10NE
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
❑ Frank Cox
❑ Larry D. Patton
❑ Glenn Thomas, alternate
❑ Don Scherr
El B. Carroll Johnson
tg NONE
El Kevin Myers
❑ Joe Wallace
❑ James Matson
❑ David Hart
❑ Charles Thomas, alternate
N Quinn Williams
❑ Hillary Jessup, Chairman
❑ Haskell Monroe
❑ Ernie Wright
NONE
Historic Preservation Committee
❑ Bill Lancaster
❑ Jane Hughey
❑ Neal Nutall, Jr.
Joint Relief Funding Review
Committee
❑ Marguerite Anthony
❑ Meredith Waller
❑ Colleen Risinger
❑ Tedi Ellison ❑ J. Kevin Byrne 0 Deborah Deitering
❑ Rusleen Maurice 0 Reba Ragdale ❑
dZNONE
❑ Jodi Warner, Chair
❑ Shawn Rhodes
❑ John Crompton
(ZNONE
Parks and Recreation Board
❑ Kathleen Ireland
❑ Jody Ford
❑ Harry Green
Planning and Zoning
Commission
❑ John Nichols, Chair 0 Glenn Schroeder
❑ Marsha Sanford ❑ Dennis Christiansen
❑ Harold Strong NONE
Design Review Board
O Joan Perry
O Gary Thomas
❑ Gary Erwin
❑ Derek Dictson
❑ Bill Davis
❑ Rick Heaney 0 Hunter Goodwin 0 Nancy Sawtelle
❑ Alan King 0 Ward Wells 0 John Nichols
❑ Susie Cox, alternate 0 Robert Rayburn, alternate NONE
❑ Jay Goss, Chair
❑ Denise Whisenant
XNONE
Zoning Board of Adjustments
❑ Joshua Benn
❑ Donald Braune
❑ John Richards
O Thomas Mather
❑ Larry Hodges
❑ Glenn Brown, City Manager
❑ Sharon Colson, Chair
❑ Kenny Mallard
❑ Don Lewis
❑ Gregg Baird
❑ Chad Jones
❑ Stephen Syptak, Chair
❑ Tom Kirkland
NONE
❑ Hugh Lindsay, Area I
❑ John Crompton, Area II
❑ Steve Arden, Area III
❑ Hugh Stearns, Area IV
❑ Andrew Burleson, Student Resident
❑ Dorthea Robinson, Alternate,
ETJ Resident
❑ Chris Scotti, Councilmember
❑ Hillary Jessup, Historic
Preservation
❑ Lloyd Wasserman, County
Commission
Research Valley Partnership
Board of Directors
❑ Larry Mariott
NONE
Wolf Pen Creek TIF Board
❑ Marsha Sanford, Vice Chair
❑ James Massey
Outside Agency Funding Review
❑ Charles Taylor
O Sheryl Welford
NONE
Northgate Tax Increment
Finance Board
❑ David Scarmardo
❑ Glenn Thomas
Comprehensive Plan Committee
❑ John Richards, Area I
❑ Brian Bochner, Area II
❑ Laurie Corbelli, Area III
❑ Jerry Cooper, Area IV
❑ Kristina Campbell, Alternate,
Student Resident
❑ Craig Hall, Resident -At -Large
❑ Lynn Mcllhaney, Alternate,
Councilmember
O 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 II
❑ 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.
O Tedi Ellison, Intergovernmental
Comm/Chamber of Commerce
❑ James Massey, Intergovernmental
Comm/TAMU Admin
❑ Dr. Clark Ealy, Intergovernmental
Comm/CSISD
❑ 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
O Dr. Colleen Netterville,
Intergovernmental Comm/BISD
❑ Margie Lucas,
Intergovernmental Conon/
Brazos Transit District
❑ Chad Bohne, Intergovernmental
Comm/TxDOT
❑ Michael Parks, Intergovernmental
CommBVCOG
❑ 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 White NONE
Brazos Valley Council of
Governments
/�
O Ron Silvia, Mayor ONE
B/CS Metropolitan Planning
Organization
❑ Ron Silvia, Mayor bEr NONE
BVCOG TMPA Regional Park
Project Advisory Board
O Lynn Mcllhaney vK NONE
BVSWMA Policy Advisory
Board
❑ Ron Silvia, Mayor ❑ Chris Scotti CONE
City Center Committee
❑ Ron Silvia 0 Ben White Cl Dave Ruesink
(,<NONE
Intergovernmental Committee
❑ Ron Gay 0 Ben White ❑ John Happ
NONE
❑ Dave Ruesink
NONE
Joint City/School
Intergovernmental Committee
❑ Ben White ❑ John Happ
Sister Cities Association
❑ Dave Ruesink .j ONE
Transportation Committee
❑ Ron Gay 0 John Happ 0 Lynn Mcllhaney
❑ Ken Fogle 0 Linda LaSuit, MPO 0 Dennis Christianson, TTI
❑ Michael Parker, BVCOG 0 Bryan Woods, TxDOT LONE
❑ Ron Gay
❑ John Nichols
❑ Joan Perry
Wolf Pen Creek Oversight
Committee
❑ Chris Scotti ❑ Marc Chaloupka
❑ Marsha Sanford 0 Jodi Warner
❑ Sharon Colson NONE
Describe each affiliation or business relationship with an employee checked in Question 4 above:
Adopted 01/13/06
CONFLICT OF INTEREST QUESTIONNAIRE FORM Cu)
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.
00;14,1 L.(J ;) awl S
A. Is the local government officer named in this section receiving or likely to receive taxable income from the
filer of the questionnaire?
Yes
r. (,0;11cu s ;s5 es" bye 1°1
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.
Nor Gv;11.0)A4 i5 0,,,4110y,01 101 k4.4 Q;,iaV
6.
0
Signature0o on doing business with the governmental entity Date
/o3
Adopted 01/13/06
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, Loca P 2-01-06P03 : 23 r<,
Government Code. An offense under this section is a Class C misdemean'
OFFICE USE ONLY
Date Received
1. Name of person doing business with local governmental entity.
2.
644 fi— ctki aw%at4r5 , .4.51C- A K
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. Name each employee or contractor of the local governmental entity who makes
recommendations to a local government officer of the governmental entity with respect to
expenditures of money AND describe the affiliation or business relationship.
Robert Alley, Fire Chief
Michael Clancey, Police Chief
Charles McLemore, Public Works
•
•
■
Steve Beachy, Parks & Rec
Joey Dunn, Planning & Dev
Becky Nugent, Public Relations
•
■
■
Glenn Brown, City Manager
Don Fazzino, Legislative Liason
Julie O'Connell, Human Resources
■
■
■
Olivia Burnside, Inf. Tech.
Kim Foutz, Economic Dev
Mark Smith, Public Works
•
■
■
Pete Caler, Landfill Mgr.
Connie Hooks, City Secretary
Ed Spillane, Municipal Judge
■
■
■
Harvey Cargill, City Attorney
Jeff Kersten, Finance
Cheryl Turney, Purchasing Mgr.
■
■
■
John Woody, Utilities
X NONE
•
4. 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.
City of College Station Elected Officials
City of College Station Committees, Boards, and Commissions
College Station City Council
B/CS Library Committee
❑ Ron Silvia, Mayor
❑ John Happ, Place 2
• Ben White, Place 1
• George McLean, Vice Chair
■ Frank Cox
Don Scherr
• Ron Gay, Place 3
• Susan Lancaster, Place 4
■ Chris Scotti, Place 5
■ Larry D. Patton
W' NONE
It NONE
• Nancy Berry, Place 6
Jo Berg
City of College Station Committees, Boards, and Commissions
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
B/CS Library Committee
Larry Ringer, Chairman
• George McLean, Vice Chair
■ Frank Cox
Don Scherr
•
• Katherine Edwards
■
■ Larry D. Patton
Eric Miller
It NONE
❑ David Ruesink, alternate
Jo Berg
•
■ Jeanne Mitchell
■
Lois Koontz
[ James Bradford
NONE
•
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
Cemetery Committee
Sarah Adams, Chair
• George McLean, Vice Chair
■ Frank Cox
Kevin Myers
•
• Virginia Reese
IN
■ Larry D. Patton
James Batenhorst
It NONE
❑ David Ruesink, alternate
Joe Wallace
•
■ Mary Lind Bryan
■
David Chester
jaNONE
•
Construction Board of
Adjustments and
Appeals/Building & Standards
Commission
• Dan B. Sears, Chairman
• George McLean, Vice Chair
■ Frank Cox
• Mike Lane
■ Larry D. Patton
■ David Hart, alternate
It NONE
❑ David Ruesink, alternate
kNONE
• Steve Parker, alternate
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
It NONE
Historic Preservation Committee
Parks and Recreation Board
Hillary Jessup, Chairman
J. Kevin Byrne
Bill Lancaster
Mary Sherwood
Marsha Crenwelge
•
■
■
■
Marguerite Anthony
Carol Blaschke
David Ruesink
• Rusleen Maurice
Dipankar Sen
•
■
■
■
Thomas Taylor
John Crompton
Ernie Wright
Harry Green
Neal Nutall, Jr.
•
■
■
■
Colleen Risinger
Rt. NONE
•
Joint Relief Funding Review
Committee
Parks and Recreation Board
Scott Shafer, Chairman
J. Kevin Byrne
Mary Sherwood
• Rebecca Eplen
■
■
■
■
Charlotte Mikulee
Carol Blaschke
Peggy Samson
• Rusleen Maurice
•
•
RLNONE
■
■
John Crompton
Planning and Zoning
Commission
Parks and Recreation Board
Scott Shafer, Chairman
Kathleen Ireland
Glenn Schroeder
•
Jodi Warner
•
■
■
Carol Blaschke
Bill Davis
Jeannie McCandless
■ Dennis Christiansen
Gary Thomas
•
■
■
John Crompton
•
Harry Green
ER NONE
Gary Erwin
•
■
■
oEI NONE
Planning and Zoning
Commission
Design Review Board
Scott Shafer, Chairman
Rick Heany
Ken Reynolds
•
• John Nichols
■
■
Marsha Sanford
Alan King
Bill Davis
•
■ Dennis Christiansen
■
•
Harold Strong
efff NONE
Susie Cox, alternate
•
Design Review Board
Rick Heany
Hunter Goodwin
Nancy Sawtelle
■
■
•
Alan King
Ward Wells
Scott Shafer
•
■
•
Susie Cox, alternate
Robert Rayburn, alternate
ER NONE
■
■
Zoning Board of Adjustments
Jay Goss, Chair
Joshua Benn
John Richards
•
•
■
Graham Sheffy
Donald Braune
Charles Taylor
•
■
■
Denise Whisenant
Derek Dictson
&Z. NONE
•
■
Research Valley Partnership
Board of Directors
Wolf Pen Creek TIF Board
David Hickson
Sharon Colson, Chair
Chris Scotti, Councilman
•
• Larry Mariott
•
■
Glenn Brown, City Manager
E' NONE
Kenny Mallard
•
Wolf Pen Creek TIF Board
Sharon Colson, Chair
Marsha Sanford, Vice Chair
Marc Chaloupka
•
■
•
Kenny Mallard
James Massey
NONE
•
■
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
a
No
D. Describe each affiliation or business relationship.
6.
Af/ii
- yal,k;•
//ZG/D l�
Signature of person doing business with the governmental entity Date
Adopted 11/02/2005