ATTACHMENT B
PUBLIC INTEGRITY DISCLOSURE
1. 2.
3. 4.
Name of Entity
?itl� �,
Addresso
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PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
rinciple Place of Business)
� ��m-.,,
Local or California Address (if ifferent th #2)
State where Entity is Registered with Secretary of State CA-\ i ti,, Mo'--
If other than Cali istered in California? Yes No
6. Officers, Directors, Members, Mana ers, Trustees, Other Fiduciaries (please specify) Note: If any response is not a natural person, please identify all officers, directors, members, managers and other fiduciaries for the member, manager, trust or other entity ----'04-"-h .... ".'.\_.__{p=-· ... ���--'----'----"-------� 0 Director O Member O Manager [name]
D General Partner D Limited Partner
□Other ____________ _
---�-=--:Jd---'�-¼....:. __ Q....::_e::::Q--=o... ________ �cer D Director D Member D Manager [name]
O General Partner O Limited Partner
□Other ____________ _
_ --1-�-=-•_l.:....\-=---�::.__:/j�t{.-=-�----':....._ _______ [3-(Sificer O Director O Member O Manager (Revised 09 13 18)
[name]
D General Partner O Limited Partner
□Other ____________ _
CITY OF PALM SPRINGS- PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
7. Owners/Investors with a 5% beneficial interest in the Applicant Entity or a related entity
EXAMPLE
JANE DOE
[name of owner/investor]
A.
[name of owner/investor]
B.
C.
[name o
D.
E.
50%, ABC COMPANY, Inc.
[percentage of
g f beneficial interest in entity
i:i name of entity)
(percentage of beneficial interest in entity
and name of entity]
[percentage of beneficial interest in entity
and name of entity]
[percentage of beneficial interest in entity
and name of entity]
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
s;gn
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of · os;ng 7• �;.d,7f;J&
Viu eJJe .... ---
Date
(Revised 0913.18)
CITY OF PALM SPRINGS- PUBLIC INTEGRITY DISCLOSURE FORM
APPLICANT DISCLOSURE FORM
Name
Board Officers
Dan Gilbertson,
Fred Bell
William L Bramer
Board Directors
Dick Shalhoub
Robert Gilliland
Fred W. Noble,
Gary Annunziata/D.0.
William Hughes
William Page/M.D
Frank Castner
Mort Gubin/M.D.
Todd Hooks
Kenny Holley
Polly Pond Holley
Fred E. Jandt P.H.D.
Andy Jessup Sr.
James Kaplan
Karen Miles
Richard Oliphant
John Parker
Carl Scholl
David Thompson D.D.S.
Rod Vandenbos
Martin Garrick
Bill Rutherford
Victor Wolf
Chairman
Vice Chair/Managing Director
Secretary fr reasu rer
Board Director
Board Di rector
Board Director
Board Director
Board Director
Board Director
Board Director
Soard Director
Board Director
Board Director
Soard Director
Board Director
Soard Director
Soard Director
Soard Director
Board Director
Board Director
Board Director
Board Director
Soard Director
Soard Di rector
Board Director
Soard Director
Affiliation
Retired/Oil & Gas Industry
Chief Operating Officer, Nobel! Energy Solutions
Retired/Business Analyst
Owner, McDonalds Franchise, Riverside County
Partner, Gurallnck & Gilliland LLP
President, Wintec Energy
DGC Digestive Health
Retired, Steel Manufacturing
Retired, Medical Doctor
Retired, Educator, Palm Springs Unifieds School District Retired, Medical Doctor
Economic Development Director, Agua Caliente Band of Cahuilla Indians Retired Founder, Advance Machine
Retired Founder, Advance Machine
Retired Educator, Cal State San Bernardino
Owner , General Motors Dealership, Coachella Valley
Owner , Harlan Tug
Captain. USAF Ret.
Principal, Oliphant Enterprises
Engineer, Boeing Aircraft Corporation
Owner, Aero Trader
Retired Dentist
Principal, Buzz Box Inc.
Principal, Admiral Development
Principal, Rutherford Investments
Attorney, Best Best & Krieger