HomeMy WebLinkAboutConflicts Disclosure Statement-Conflict of Interest-8/30/2006
CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendor or other person doing business with local governmental entity
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This questionnaire is being filed in accordance with chapter 176 of the-toeal
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.
1 Name of person doing business with local governmental entity.
Dannenbaum Engineering Company - Fort Worth, LLC
D 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.
NONE
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 governmental entity that is the subject of this questionnaire.
NONE
Amended 01/13/2006
CONFLICT OF INTEREST QUESTIONNAIRE
FORM CIQ
Page 2
For vendor or other person doing business with local governmental entity
~ 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 CIO 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?
DYes
DNO
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?
DYes
DNO
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?
DYes
DNO
D. Describe each affiliation or business relationship.
~ Describe any other affiliation or business relationship that might cause a conflict of interest.
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Signature of person doing business with the governmental entity
Gary W. Fisher, P.E., President
Date
Amended 01113/2006
DANNENBAUM ENGINEERING COMPANY - FT. WORTH LLC
6421 CAMP BOWIE BLVD.. SUITE 400 FT. WORTH. TEXAS 76116 (817) 763-8883
August 22, 2006
Office of the City Secretary
City of Colleyville
100 Main St.
Colleyville, TX 76034
RE: CONFLICT OF INTEREST QUESTIONNAIRE (FORM CIQ)
Pursuant to House Bill 914, we hereby submit Form CIQ (Conflict of Interest
Questionnaire) for your record.
Please feel free to contact me if you have questions regarding this submission.
Sincerely,
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Gary W. Fisher, P.E.
President
G:\admin\Conflict of Interest\Transmittal Letter\Transmittal Letter 2006.doc