CONIlUCT0' INTEREST QUESTIONNAIRE,"or vene:ior or other per80nd" ~In e ~h lode' gdwmm-tllll entity FORM CIQ

Transcription

1 ,. FAX NO. : Ma e! : 13Pf-1 P3 CONIlUCT0' INTEREST QUESTIONNAIRE,"or vene:ior or other per80nd" ~In e ~h lode' gdwmm-tllll entity FORM CIQ..., of a,.,. queattonnalfe Ie ~.m.d In 80001~ wjfh chapter 118 of the OI'I"JGI! use ONLy ~II Oowmment Code by B person doing bublrih8 with the ~..., govllrnmental entity By law \hla qumticlfl".ba mu8t be fted <11th the J'OOQfUo admlnl'1i1i&or.of 1M IooeJ ga\lllmltmll1t not 'aterthemlhe 7th bu.in... day after the date the perbon beoom..aware 0( facta that r.-qul", tm.hatlllment to b6 fltllld. SH section , Local Government eoo.. A purson cortlmft. an offense If the plllraon vlolalea Secflon , 1..ocaI QovernJbent-Cod.. An Mf.n.. Llndcr this section II a CIa. C mled '. Midwe8~ Dental Equlpment & Supply

2 FROM :MIDWEST DENTAL SUPPLY FAX NO. : Ma~ :13PM P2 CONFLICT OF INTEREST QUESTIONNAIRE for MMor or ~r pwmn doing bwlnell w11t'l1dc11 gowrnmenml,mull FORM CIC ",,2..'2 My"... Ia A Of C Ie "f!8.j ThI..4IdIort.. Mam S.,..,...,~~.8, C "0, ~ be II"'~ h._ttl ~lic.t I.tItlIM1clm,_ Ihr MUl'lIIallon or llallnem n*uonllllp. AIl-.:1l1lddl11on1l P8C1811O VII. FDfm CIa l\iic8l&8ry. A.,. the loodi.gowmtfl8l1f otno.r r1iiifltd In UIM IBtaln,"wing Gllllllly to,..c.f\16...ble IIIcome ',om 1M 1"*, of tt\e qu.aonn.,.?... que8ldnnan '1ICeN1nII Dr IIIceIV fa lwoeiw "lliibte IncQtfte frot'l ~ -',"- dllwcuo(i 01 the IaCIII B. I. "*II.of OOV.",ftlMI off":. nii""_ In 'hill ~AND fie ta.bi.liieom. I, nai'l'dlft the local gtil111m"","'" ~'1 Dvell ;("No c, '- lhe.itt'an",. wn'ioni\1ln IIIlIIIIIted wilh. CIOrpolBtlotl or olt,. bulln... enlll~,hat It"O ~I fiow...,.".,,1 orne. NIII... M orbr Of di~()(, 01( hoida In lwl/ner'hlp of 10 "ra.", 01 mon~ Ov.. ~o DNe,, Nang

3 Page 1 of2 I 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 , Local Government Code. A person commits an offense if the person violates Section , Local Government Code. An offense under this section is a Class C misdemeanor Name of person doing business with local governmental entity. OFFICE USE ONLY Date Received t,i I. 'I I, 2 o Check this box if you are f1llng an update to II previously filed questionnaire. (The law requires that you tile an updated completed questionnaire with the appropriate filing authority not later than September I of the year for which an activity Jesl.:ribed in Section (a), Local Government Code, is pending and not later than the 7th business day after the date the originally tiled questionnaire becomes incomplete or maccurate.) 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. 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. V PUl'chaseRFP / Graphics & Publications Software Management Page 15 of 16

4 Page 2 of2 5 Name of local government officer with whom flier has affiliation or business relationship. (Complete this section only if tbe 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? D Yes ~ No B. Is the filer of the questionnaire receiving or likely to receive taxable IOcome 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 r&. 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? Dyes ~NO D. Describe each affiliation or busloess relationship. 6 Describe any other affiliation or business relationship that might cause a conflict of interest. 7 Signature of person doing business with the govellunental entity Date V:PurchaseRFP / Graphics & Publications Software Management Page 16 of 16

5 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 , Local Government Code. A person commits an offense if the person violates Section , Local Government Code. An offense under this section is a Class C misdemeanor. 1 Name of person doing business with local governmental entity. Page 1 of2 OFFICE USE ONLY Dale Received MetaCommunications, Inc. 2 o Check this box if you are fjjing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority nollater than September I of the year for which an activity described in Section I76.006(a), Local Government Code, is pending and not later than the 7th business day after the dale 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. 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. Amt.:ndcd n006 Am~nded 01/13/2006 MetaCommunications Inc. Page 34 04/24/09 <92009 MetaCommunications. Inc. All rights reserved. MClaCommunications, thc MetaCommunications logo, Workgroups, Virtual Ticket, Job Manager, Approval Managcr, and Digital Storage Manager are trademarks of MetaCommunications. Additional company and product names may be trademarks or registered trademarks ofthc individual companies and are respectfully acknowledged.

6 Page 2 of2 5 Name of local government officer with whom tiler 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 tiler 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 tiler of the questionnaire? DYes D 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? DYes D 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'} DYes D No D. Describe each affiliation or business relationship. 6 Describe any other affiliation or business relationship that might cause a conflict of interest Date MetaCommunications Inc. Page 35 04/24/ MeUlCommunications. Inc. All rights reserved. MelaCornmunications, the MetaCommunications logo, Workgroups, Virtual Ticket, Job Manager, Approval Manager, and Digital Storage Manager are trademarks of MeUlCommunications. Additional company and product names may be trademarks or registered trademarks octhe individual companies and are respectfully acknowledged.