HomeMy WebLinkAboutNash CIQCONFLICT OF INTEREST QUESTIONNAIRE
For vendor or other person doing business with local governmental entity
FORM ClQ
Page 2
Name of local government officer with whom file[' 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 relafionship. Attach additional pages to;this Form CIQ as necessary.
A. ts the local government officer named in this s~ction receiving or likely to receive taxable income from the filer of the
questionnaire?
B. Is the flier of the questionnaire receiving or likel~ to receive taxable income from or at the direction of the local govemmer4
officer named in this section AND the taxable ihceme is not from the local governmental entity?
r-q ,f-es ~ No
C~ Is the filer of this questionnaire a~liated with a ~:orporation or other business entity that the iocal government officer ser~es
as an ofr~cer or director, or holds an ownership of 10 percent or more?
[-'---]Yes ji~"'No
D. Describe each affiliation or business relationship,
Describe any other affiliation or business relationship that mlgltt cause a conflict of interest.
7_J
Signature of person doing business with the governmental entity
CONFLICT OF INTEREST QUESTIONNAIRE FORM
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 commits an offense if the person violates Section 176.006, Local
Government Code. An offense under this Section is a Class C misdemeanor.
'i~ Name of person doing business with local governmental entity.
~-~heck this box if you are filing an update to a previously filed questionnaire.
(The taw requires that you file an updated C°mpieted 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 th~ 7th business day after the date the 0rigina]iy filed questionnaire becomes incomplete or inaccurate.)
~ Describe each affiliation or business relationship with an employee or contractor of the local governmental entitywho makes
recommendations to e local government officer of the local governmental entity with respect to expenditure of money.
4_..J Describe each affiliation or business relationship with a person who is a local government officer and who appointe or
employs a local government officer of the local governmental entity that is the subject of this questionnaire,