LOCAL GOVERNMENT OFFICER FORM CIS

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1 LOCAL GOVERNMENT OFFICER FORM CIS CONFLICTS DISCLOSURE STATEMENT (Instructions for completing and filing this form are provided on the next page.) This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This is the notice to the appropriate local governmental entity that the following local government officer has become aware of facts that require the officer to file this statement in accordance with Chapter 176, Local Government Code. 1 Name of Local Government Officer B f.. OFFICE USE ONLY Date Received 21 Office Held - J 31 Name of vendor described by Sections (7) and (a), Local Government Code... IJ Description of the nature and extent of each employment or other business relationship and each family relationship with vendor named in item 3. c. 51 List gifts accepted by the local government officer and any family member, if aggregate value of the gifts accepted from vendor named in item 3 exceeds $100 during the 12-month period described by Section (a)(2)(B). '; Description of Gift Description of Gift Description of Gift (attach additional forms as necessary) 61 AFFIDAVIT I swear under penalty of perjury that the above statement is true and correct. I acknowledge that the disclosure applies to each family member (as defined by Section (2), Local Government Code) of this local government officer. I also acknowledge that this statement covers the 12-month period described by Section (a)(2)(B), Local Government Code. Signature of Local Government Officer AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said, this the day Of 20 to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath Form provided by Texas Ethics Commission Revised 11/30/2015

2 Skip Navigation Global Navigation SAT (SAT) ( AP (Advanced Placement) ( College Planning ( College Search ( Professional Development ( Store ( More AP Central ( K-12 Services ( Higher Education ( College Guidance ( En Español ( ( Home (I) Program (/program) Registration (/registration) Travel (/travel) 2015 Highlights (/program/highlights-2015) Contact Us.(rn.ailto.;sp.uthwesternthcqlleaeboard.on REGISTER NOW Travel Hilton Dallas Lincoln Centre Print form ( 2016/regional-forum_registration-form pdf) or register online ( meetingld ) for the 2016 Conference HIGHLIGHTS L, 4-A - View highlights (/program/highlights-2016) for the plenary sessions at the 2016 Southwestern States Regional Forum. FOLLOW US ( mode=welcome_gi_new&groupld= ) 5410 LBJ Freeway Dallas, TX Directions to Hilton Dallas Lincoln Centre (htlp:/1www3.hilton.com/enihotels/lexas/hilton-dallas-iincoln-centre- DFWLTHH/maps-direclionslindex.hlml) Hotel Reservations Join the conversation tweet with the hashtag #ForumSW I ( #ForumSW - ( q=forumsw&srctypd) A discounted room rate is available to 2016 Regional Forum attendees on a first-come, first-served basis at the Hilton Dallas Lincoln Centre. The room rate for a standard single or double room is $159 per night plus applicable taxes. To obtain this special rate, reservations must be made by Feb. 10, Make your reservations online ( mode=welcome_gi_new&groupld= ) or by phone at and be sure to mention the College Board Southwestern Regional Forum. Room rates are for Forum conference attendees only. Please do not book more room nights than you need for the conference. If you have to cancel your hotel reservation, please do so as soon as possible. Timely cancellation helps ensure that rooms are available for other conference attendees, especially before the cutoff date.

3 World :Trve1 INC. (c instant Feedback I Ticket Detail Contact Us Remarks Important Company Details Travel Information Brittain/Lisa M January 15, :44 PM World Travel Record Locator: P4LWJB Southwest Airlines Flight WN253 Economy Class Airline Booking Reference: RF4BKM Depart: AUS - Austin-Bergstrom Intl I Austin, Texas, United States Arrive: Duration: Status: Equipment: Seat: FF Number: Important Company Information: Remarks: 09:20 AM Wednesday, February 24, DAL - Love Field, Terminal I Dallas, Texas, United States Li 10:15 AM Wednesday, February 24, hour(s) and 55 minute(s) Non-stop Confirmed Boeing (winglets) Passenger Assigned at Check-in BRITTAIN/LISA M If you change your seat assignment directly with the airline, please contact World Travel so that our automated seat changing processes won't cause your seat to be changed. YOUR SOUTHWEST CONFIRMATION IS RF4BKM Southwest Airlines Flight WN2961 Economy Class Airline Booking Reference: RF4BKM Depart: DAL - Love Field, Terminal I Dallas, Texas, United States 05:05 PM Friday, February 26, 2016 Arrive: AUS - Austin-Bergstrom Intl -: Austin, Texas, United States L 06:00 PM Friday, February 26, 2016 Duration: 0 hour(s) and 55 minute(s) Non-stop Status: Confirmed Equipment: Boeing Passenger Seat: Assigned at Check-in FF Number: BRITTAIN/USA M Important Company If you change your seat assignment directly with the airline, please contact World Travel so that our Information: automated seat changing processes won't cause your seat to be changed. Remarks: -- YOUR SOUTHWEST CONFIRMATION IS RF4BKM --

4 Ticket Number: New Ticket Charges: Service Fee: Total Charges *: Invoice Number: Ticket and Service Fees charged to: Issued: 01/15/2016 Southwest Airlines issued: 01/15/ * Some airlines have instituted new baggage fees. Use the link below for details. USD USD USD USD Booking Agent: Dee Pearl Emergency Contact (24/7) within the US: International (Outside of the U.S.): Visit us at: worldtravelinc.com RESERVATION MADE BY DEE PEART THIS TICKET IS NON-REFUNDABLE - PENALTY APPLIES FOR CHANGES. Download the WorldMobileTM app here] [ Find vacation deals [III Baggage & Ancillary Fees J 1 Add Trip to Calendar J Federal law forbids the carriage of certain hazardous materials, such as aerosols, fireworks, and flammable liquids, aboard the aircraft. If you do not understand these restrictions, contact your airline or go to HazMatSafetv by clicking the link. You may access your current reservation before or during your travel dates at ViewTrip by clicking the link. Please review your itinerary upon receipt. World Travel will not be responsible for any discrepancies on this itinerary if not notified within 24 hours of when reservation was made. World Travel Corporate Headquarters WSchuylkill Road - Douglassville, PA 19518

5 2016 Regional Forums regionalforums.collegeboard.org 0 CollegeBoard Registration Information Select the regional forum (s) you are registering for. Li Middle States, Baltimore, Jan Li Midwestern, Chicago, Feb. 8-9 U New England, Boston, Feb. 4-5 Li Southern, Orlando, Feb Li Southwestern, Dallas, Feb Li Western, Seattle, Feb Please check the rate* that is most appropriate: Early Full Conference Registration Regular Member 11$275 U$320 U$200 Nonmember U $350 U $395 U $275 Presenter/Committee U $220 U $220 U$160 Student Rate U $100. U $100 U$50 Promo Code (If applicable): One-Day Registration *your selection(s) will be verified against the registration deadlines posted on the individual regional forum sites, which can be found here: regionalforums.collegeboard.org. Attendee Information Li Do not send me information and news regarding College Board services, products, and other offers via . Payment To submit this form, print, add your payment information by hand, and fax to Credit Card Payment Your credit card will be charged the lowest appropriate rate depending on the membership status of your institution on College Board records. Card Type [ Expiration Date Card Number I Name of Card Holder Ill Signature - 1 Purchase Orders and Checks When sending payment, include a copy of this form or your invoice with your check or PO, and list the last name of the registrant with "2016 Regional Forum." Checks should be addressed to "The College Board Regional Forums 2016" and mailed to 411 Lafayette Street, Suite 201, New York, NY The College Board Federal Tax ID number is P0/Check Number Cancellation Policy: There is a $75 nonrefundable cancellation fee if a cancellation is sent to forum@collegeboard.org on or before 15 business days prior to the start of the regional forum (by 5 p.m. EST). No refunds or credits will be issued on cancellations after the respective date. Substitutions are accepted, but please forum@collegeboard.org with the name, job title, organization, phone, and address information of the new registrant. Confirmation and Invoicing: Registrants will receive an confirmation within two business days. A hard copy of your invoice will be mailed within two weeks. Electronic invoices are available upon request. Hotel Reservations: Each region has secured a special group rate at their respective venue. Please visit the regional forum hotel links available here: regionalforums.collegeboard.org. The College Board frequently videotapes and records its events and meetings. By attending this event you consent to being recorded and/or photographed, and authorize the College Board and/or its agents or licensees to use any recording and/or photographs, as well as any statements that you make ("Footage"), in any medium (including, without limitation, audio, video, print, broadcast, etc.) throughout the world at the College Board's sole and exclusive discretion. The College Board may also edit, distribute, exhibit, publicize, advertise and otherwise exploit the Footage in all media and formats, now known or hereafter developed, for commercial and noncommercial use. College Board and the acorn logo are registered trademarks of the College Board _012

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