Conflict of Interest Form (PDF - 86KB)
CONFLICT OF INTEREST QUESTIONNAIRE - FORM CIQ
For vendor or other person doing business with local governmental entity.
This questionnaire reflects changes made to the law by the H.B. 23, 84th Leg., Regular Session.
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 commits an offense if the person violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.
OFFICE USE ONLY
Received July 24, 2017
1. Name of person doing business with local governmental entity.
Aves Audio Visual Systems, Inc.
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 176.000(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 of local government officer about whom the information is being disclosed.
Name of Officer
4. Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B each employment or business relationship described. Attach additional pages to this Form CIQ as necessary.
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor?
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local government entity?
5. Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of 1% or more.
6. Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding the gifts described in Section 176.003(a-1).
7. Signature of vendor doing business with the government entity