Docusign Envelope ID: 52DCB458-6FED-4D3F-B8EB-B3B8D9F9E4CA
Address of Business Entity:
Nature of the regulation of the Entity by the Duchesne County (including any licenses, permits, etc.):
Nature of the business which the Entity does or anticipates doing with the Duchesne County:
Nature of the transaction involving the Duchesne County for which you may receive or agree to receive compensation from the Entity for assisting, including a description of the services to be performed and the compensation to be rendered:
DISCLOSURE OF OTHER PERSONAL INTERESTS
Please disclose any other personal interest or investment which creates or has the appearance of creating a conflict between your public duties and your personal interests.
Name of the Business Entity or Person: * (Write NA if not applicable.)
Address of Business Entity or Person:
N/A
Principal Activity Engaged in by Entity:
Nature of Investment or Involvement: