Laserfiche WebLink
<br />CITY OF ELK RIVER HRA <br />OWNER-OCCUPIED REHABILITATION PROGRAM <br /> <br />APPLICANT CONFLICT OF INTEREST DETERMINATION <br /> <br />You have applied for a rehabilitation loan through the Elk River HRA. The program has policies and <br />procedures in place to address any conflict of interest of an applicant. Please complete this form to <br />determine of additional steps are needed: <br /> <br />Have you or your company, in the last 12 months, been a: (check all that apply) <br /> <br /> Employee ____ <br /> Consultant ____ <br /> Officer ____ <br /> Elected Official ____ <br /> Appointed Official ____ <br /> NONE of the above ____ <br /> <br />Of the… <br /> <br /> State of Minnesota ____ Name Agency: <br /> <br /> Local Government ____ Name Position: <br /> <br />Or, do you/have you or any immediate family member had a business relationship with any of the above <br />named persons? <br /> <br />If yes, please describe: <br /> <br /> <br />I/we certify that the information is true and correct to the best of my/our knowledge. <br /> <br /> <br /> <br />Signature of Applicant Date <br /> <br /> <br /> <br />Signature of Applicant Date <br /> <br /> <br />Note: If a conflict exists, the city and program administrator will review conflict to determine if an <br />exception to the conflict can be approved. <br />6 <br /> <br />