Durable Specialties, Inc.CONFLICT OF INTEREST QUESTIONNAIRE .
For vendor or other person doing business with local govemmental entity
FORM CIQ
This questionnaire reflects changes made to the law by H.8.23,84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business elationship as definedby Section 176.001(1-a) with a local govemmental entity and the vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local government entty not later than the 7th business day after the
date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Govemment Code. An offense under this section is a
misdemeanor.
Check thi8 box if you are tiling an update to a previously tiled questionnaire.
(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7t business day
after he date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.)
:{ame oflocal government officer about whom the ioformation in this section is bcing discloded.,//4
Name of Officer
Describe each employrnent or other business relationship with the local golemmefit ollicer, or a fmily member ofthe officer, as described by Section
176 003(aX2XA). Also describe any fanily relalions hip wilh the local govemment officer. This section, (itom 3 including subpans A, B, C & D), must be
conrpleted for cach officer with whom the !e dor has an employr.ert or other business relationship as dcfinedby Section 176.001(1-a), Local Covemnrent Code.
Aftach additional pages to tfus Form CIQ as neccssary'.
A. ls the local govemment officer narned in this section receiving or likely to receive taxable income, other than invcstnrcnt incorne, fiom the vendor?
B. Is the vendor receiving or likely to receive t&\able income, other than investmenl income, Irom or at the direction ofthc local govemment oflicer narned in
this section AND the taxable income is not received fmm the local Bovemmental entity?
Ycs No
C. Is the {iler otthis questionnaire ernployed by a cor?oration or oller business entity with respect to u4ich the local govemment offic,er serves as an ollicer
or director, or holds an ownership ofone percent or rnore?
Yes No
D. Dcscribe each employment or business and fixnily relationship with thc locai govemment officer namcd in this section
I ff na"e no cortlict of lnterest to disclose.
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Signatue of vendor doing business with the goverlunenlal enlity [)atc
Name of vendor who has a buain€ss r€lationship with local govemmsntal entity.
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