HomeMy WebLinkAboutAgreement A-17-464 with American Ambulance (Sierra).pdfIN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day
2 and year first hereinabove written.
3 ATTEST:
4 K.W.P.H. ENTERPRISES, dba
5 AMERICAN AMBULANCE
6 By-~ 7
8 President, K.W.P.H. Enterprises
9
Print Name: _\..:...:o:.:~=C~~_:_~~..l!:!~=i~\~.--_
Date: D\ J\q /\]
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By~ 12
13
14
15
Print Name: /!r1 A ~ ~.fet--.f<~o/\
Title: Cor-pc.ro_k Secll'e.t~r~;~
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16 Date: 1-J'-/-11
17
18 Chief Financial Officer or Corporate
19 Secretary to K.W.P.H. Enterprises
20 d.b.a. American Ambulance,
21 a California Corporation
22
23 Mailing Address:
24 2911 E. Tulare St.
25 Fresno, CA 93721
26
27 PLEASE SEE ADDITIONAL
28 SIGNATURE PAGE ATTACHED
COUNTY OF FRESNO
Fresno. Califomia
14
COUNTY OF FRESNO
t~L By __ ~--~--~-----------
Chairman, Board of Supervisors
Date: hc.rm;~ Jd ,aol'\
ATTEST: BERNICE E. SEIDEL, Clerk
Board of Supervisors
Exhibit B
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as “County”),
members of a contractor’s board of directors (hereinafter referred to as “County Contractor”), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
“A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest.”
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member’s name, job title (if applicable), and date this disclosure is being made.
(2) Enter the board member’s company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the Corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation’s transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit B
Page 2 of 2
(1) Company Board Member Information:
Name: Date:
Job Title:
(2) Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to):
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233 (a):
(5) Authorized Signature
Signature: Date: