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Jan -19-2016 9:59AM ER Energy Recovery Station No.0161 P. 2 <br />Conflict of Interest is defined as the participation in any actMtq, recommended action, or decision <br />from which the individual has or could have the potential to receive personal gain, whether it be <br />direct or indirect. (See attached "Conflict of Interest" Ordinance) <br />In accordance with this definition, do you have any legal at equitable interest in an business, <br />howcvtr oxguized, which could be construed as a conflict of interest?aes ✓ No <br />If yes, provide details n orate piece Ofninct. <br />Applicant Signature Date <br />Questions .cnay be directed to the Administration Department at 763,635.1000. <br />OFFICE USE ONLY <br />New Applicant ❑ Reappointment <br />Council Meeting Date - <br />0 Appointed to: <br />Term Expires - <br />13 NotA.ppointed <br />