HomeMy WebLinkAboutArmstrong Forensic Laboratory 2023CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ
For vendo'ir in busirtess, with local governmental leatilty
thi's quagumnalra leftects 6hangos meads 10 the to by, H,V, 23, e4rh I gig., PaguUr Sossion. OrRCE USE ONLY'
Thit Pt bon eg Nod A11 Chaptai 176, Uwcal Grwernmwil kq o vondrAr M,io
has a business ra),arkoi%Np a% defl"od by Sod w�� 176 Mth o be.al govornmerA6,11 antiry wid 16he
vardim mulads reqLkeri wints under Sector[ � 76 001%a)
av km ev's rrirusi bqi filed with fiie records adm#n�,slraRar aJ ft rocal govowrawfitar arviky n,)t Iauor
V rtflot Iauol
Ithm, 1hn Nh I l,%xrJnes5 day gifter One date rnok vwuk r bVc*rVwA awato 04 fL'lds [hot ierau48, the starkemerrt to be
flWl See Sedon 170 00e,,a. 1), IlLocc af, Govarnment Qoda
A vuodw cewimlu poi Aww of 9 m venrkx kl-MWhlg4Y Valare., secdon 1775 006, oca4 r4ovw nment C%lo 'err
offwme undo �vs ��ecrlrmi Is �a im sdwywsapor,
I —I,of vendor who has a businless, relationstrip, witt) llo aj governorenta4 entjiy,,
(JqWresthariy our fllbanu),
ss day after The ff we cm which
you becarne aware that t1he orlq rjafly fi d qwn*)r,oi,ajr0 'was 6aor rnpWlle or oaccurcate
!is being di"Josed,
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Narne �o9 r-Aceir
Describe each employment or other business relleflonablip with the focal government offliGer, ora farnlilly "l ember of the
offl�vrw , as devcadbed k7y %94-�n 170.00,2fa)(2)(At, Alw�o aqawgrWo any lardy rarorlanafflp wifl-t ffic b>eal goverp"C"t officem%
CompletoaubparlsAandiB or each, amrAloyment or busimeas relationjoNp dosorlb-04, Attaochadditional pages, to thi Iprrrrn
CIO'arrow c s ry"
A 4�/�he k)�lv 04,pWrnmeiil officeir lor a t �,y member of fli,@ off icer rem., M ng or We �y to receive tLu abW
other thari lnvrevrriew Ot,*,rne, froin �1rlidbO,
El I N's 0 1,40
B. JV ;; thevendw rec4vrig or Hkely to ter*lve trxx** rricome, othe, rhanirvesImer'll ljrrcfxne, from or al the diractiicn
,of ffie 1,ocal jpvornmarl offictir 0 r I faffflfy rnarnbeir irrl 8,444 afflcor ANDihp. faxntfln urw� nn o Is ncul N,enj,jypoj �,,Tnrp t,)7r
boW pmrnmenial entity?
ElYes No
—nDesctaih4e. eachh arnployerrent or buslrrei, s relati onsllip that the vendor TIMITled in Seoion I nraintains will a o"Poralion or
rather Vera giness, lonfity with respect t chic the loced gover nment officer solves an officer or dirloctof, or hojxjs an
ownership interoal of one pefoont of more,.
. .. . . . .......... . ...
Clieck Oils Wx V I W vesxfor tuft gpVOrr qlF,4 VMa� 901YUMMerit officer or a fxnRy rneuribgr ol th* &VOOr DnO fir Mrj(Hg)lt$,
as described In $',q(%ojn 176 excIuding g0ts dieserbadl rn Section 176,0M(a-1)
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Y A192411
Form pmvidlad by 'Tax as Ethics bra miasim RoOsed M'302015