Mark Hansen, Environmental Quality and Energy Commission
City of Fridley
Public Disclosure Statement
By Members of Advisory Bodies
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Name: Date
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Position Title:
Pursuant to Section 5.05 of the Fridley City Code, I hereby make the following declarations regarding my
financial and personal interests:
1. Names of all business corporations, partnerships, other business enterprises, or governmental agencies
doing business with the City of Fridley or located within the City of Fridley.
a) With which I have a financial interest
As used in Chapter 5, the term financial interest shall be deemed to include ownership of more than
10% of: the outstanding stock in a corporation, an interest in a partnership, proprietorship, or other
business entity, or an interest in real property. Financial interest shall apply to real or personal
properties owned by one person making the disclosure and by said person’s spouse.
b) With which I have a personal interest
As used in Chapter 5, the term personal interest shall be deemed to apply whenever a person
required to make a disclosure under this code of ethics shall be associated with a business as an
employee, officer, director, trustee, partner, advisor or consultant.
Name of Business, AddressFinancial Interest Personal Interest
Partnership, Etc.
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(use additional paper if necessary)
2. A list of the non-homestead real property located within the City of Fridley in which I currently have a
financial interest:
Non-Homestead Real Property Address
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(use additional paper if necessary)
I do swear (or affirm) that this report is a full and true statement pursuant to Section 5.05 of the Fridley City
Code.
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_____________________________________________ ___________________________
Signature Date
This statement must be filed upon appointment or reappointment to an advisory committee or material
changes in financial interest while on an advisory committee. Please submit a signed Public Disclosure Form
to the City Clerk’s Office. Thank you.