RFP #22
-051
Attachment “C”
CONFLICT DISCLOSURE FORM
N/A
Andrea Knight / Koury Engineering and Testing, Inc.
Client Manager
3/29/2022
N/AN/A
CONFLICT DISCLOSURE FORM
CITY OF RJALTO
DISCLOSURES REQUIRED BY PERSONS OR ENTITIES
CONTRACTING WITH THE CITY OF RIALTO"
Pursuant to City of Riatto Municipal Code Section 2.48.510, all persons or business entities supplying any goods or services to lhe cily, or seeking a loan or granl awarded by the city, whether through an application or proposal, shall drsclose n such application or proposal whether any dty officer, employee, or consuttant may have a financial or non-rlnancial Interest In lhe person or business entity, or in any member, employee, owner or officer of the business enlity. • A financial Interest shall mean any interest that is prohibtled under state law, including Galiromia Government Code SecHons 1090 and 87100, and California Code or Regulation Section 18700 et seq.
• A non-financial interest shall mean any Interest lhal is prohibited by Cfty of RlallO Municipal Code Section 2.48.450.
For the purpose of helping the City understand whelher City personnel might have a conflict of Interest In you or your organlzatk>n, please disclose below whether you or any or your members, employees. paid or unpaid officers, paid or unpaid directors, or owners are (or are related to) a City elected or appointed offidal, a City officer, or a City employee or consultant.
Relationship Between the
Nam• of Your Organization'• Name of City Elected or Two Affected Member, Employ•, Appointlld OfflCNII, City
Paid or Unpaid Offl�r, Paid or Officer, a City EmployN or Unoaid Director. or Owner Conault•t
None None None
By submitting this (applicationtproposaij, or supplying any goods or services to the Qty, the [applicantlvelldor/conlractorloonsultant] hereby attests under penalty of perjury, personally a ndfor on behalf of the entity [submitting this application/p,oposal or supplying any goods or services to the City] that no City of Rialto electoo or appointed official. employlffl or consultant has a financial or non-finarrial interest as such l.emi-s are defined in Cal ifomia Government Code Sections 1090 and 87100 and in City of Rialto Code of Ordinances Section
2.48. 145, in the (applicant/vendor/contractor/consullant), except as specifically disdosed herei11.
Name of PersorvEntity: Michelle Elliott/ MTGL, Inc.
TiUe: Owner/CEO
Signature: 11.m-=
Form Date 11/11/2021
Date: _0_3 _/3_1_/2_0_22 __ _
RFP #22-051
Attachment "C"