Docusign Envelope ID: 1D87A011-546E-4BED-913F-3918B5C13ACA
Address of Business Entity:
Nature of the regulation of the Entity by the
Duchesne County (including any licenses,
permits, etc.):
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.)
NA if not applicable.)
Address of Business Entity or Person:
NA
Principal Activity Engaged in by Entity:
Nature of Investment or Involvement: