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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity

OFFICE USE ONLYThis questionnaire is being filed in accordance with chapter 176 of the Local Government Code by a person doing business with the Oale Received governmental entity. By law this questionnaire must be filed with the records administrator of the local govemment 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. Name of persol1 doing business wIth local governmental entity.

o Check this box If you are filing an update to 8 previously filed questionnaire.

(The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than September 1 of thlt 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. )

Describe each affiliation or business relationship with an employee or con1raclor of the 10<:31 governmental entity who makes recommendations to a local government officer of the local governmental en1tty with ntspect to exp~nditur'e of money.

Describe ellch affiliation or business relationship with a person who is a local government officer and who appoln1s or employs a local government officer of the local governmental entity that is the subject of this questionnaire.

V:PurchaseRFP2008-0':l £nitial~ Page 38 of)9 REP IO·OO8C<lFying&PriDtingServiceslSCS05.14.09

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CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor or other person doing business with local governmental entity Page 2

Name of local government officer with whom flier l1as affiliation or business relationshIp. (Complete this section only tf 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 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 question naire?

DYes !:!rNo

B. Is lt1e 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 entily?

Dyes [0"'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 dlredor. or holds an ownership of 10 percent Of more?

Dyes 0"No

D. Describe each affiliation or business relationship.

N4 Describe any otnerl dffiliation or blJsiness relationship that might caU68 a conflict of Interest.

Dat~

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Internal Services 7145 W Tidwell

Houston, TX 77092 EduaraiS()1uonm Phone 713-744-8129 Fax 713-744-8169

FAX Date: 6/2&'09 Number of pages including cover sh~et:

To:

Phone:

Lone Star College System

ATIN: Trisha Narinesingh

Fax phone: 832-8 J3-6513

From: Region 4 Bryan Tucker

Phone: 713.744.8129

FAX: 713-744-8169

Conflict of mterest Fonn

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CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity

FORM CIQ

This questionnaire is being filed in accordance with chapter 176 of the Local Govemment 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 176006, 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

Date Reee' ed

1 Name of person doing business with local governmental entity.

2

o 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.

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.

VPurchaseRFP2008-09 Page 38 of JC) RH'10-00SCoPYll1g .Pril1lingSCl'\iccsLSCSO~.1 ~ "

CONFLICT OF INTEREST QUESTIONNAIRE For vendor or other person doing business with local governmental entity

FORM CIQ Page 2

5 Name of toea I government officer with whom filer has affiliation or business relationship. (Complete this section only if the answer to A, 8, or C is YES.)

This section, item 5 including subparts A. 8. C & D. must be completed for each officer with whom the filer has affiliation or business relationsllip. Attach additional pages to this Form CIQ as necessary.

A. Is the local govemment officer named in this section receiving or likely \0 receive taxable income from the filer of the Questionnaire?

o Yes ~NO

8. 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 !iZNo

C. Is the filer of this questionnaire affiliated with a corporation or other business entity that the local govemment officer serves as an officer or director, or holds an ownership of 10 percent or more')

DYes ~o

D. Describe each affiliation or business relationship.

6 Describe any other affiliation or business relationship that might cause a conflict of interest

7

signatu{j of person doing butess with the governmental entrty Date

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CONFLICT OF INTEREST QUESTIONNAJREFORM CIQ For vendor or other person doing business with local governmental entity

OFfICE use ONLY 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. Sea-Section 176.006, Locai Govemment Code. A person commits an offense if the. person viotates Section 176.006, Local Government Code. An offense under this section is a Ctass C misdemeanor.

This questionnaire is being filed in accordance with chapter 116 of the

2 V ....;

o Check this box If you are "ling an update to a preViously filed questlol'''.''''',

(The law requires that you file an updated completed qu~tlonnaire with the appropnate flUng aUlhority nOllater than September 1 of the yeador whtch an activity descrlbed tn Sec1\on 176,006(a). Local Govemment Code. Is pending and not later than the 7th bLUiinefiG day after the date the originally filed questioonaire becomes incomplete or Inaccurate.)

J O..crlba uch afflUaUon or b~ IBJa-tlonshlp wJth an empJO)/H or cotl-tnIctoI or the local govf1mmental entity who m~kes rec:ommendatioml to a toeal government officer of the iocal governmental entity with respect to exptlrtdlture of money.

f

• Describe .ach afflliation or busIness rel8tlonshJp with a pel"80n who is a local government officer and who appofnts or employs a local government officer of the local governmentsI enUty that 13 the subject of thIs questionnaire.

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