"I-65 Corridor Applicant Disclosure Statement:
"APPLICANT:_________
"ADDRESS:___________
"CITY, STATE, ZIP:_______
"TELEPHONE NUMBER: ()________
"If yes, identify below the person(s) hired:______________
"If yes, identify below the person(s) hired:
"Name of Public Official/Employee__________
"Address__________________________
"Government, Department, or Agency________________
"Name of Family Member__________________
"Address________________________
"Name of Public Official or Employee__________________
"Government, Department, or Agency Where Employed
"If you identified individuals in items (3) and/or (4) above, describe in detail below the financial benefit to be gained by the public officials, public employees, and/or their family members as the result of the applicant's designation as a project. (Attach additional sheets if necessary.)
"Describe in detail below any indirect financial benefits to be gained by any public official, public employee, and/or family members of the public official or public employee as the result of the applicant's designation as a project. (Attach additional sheets if necessary.)
"List below the name(s) and address(es) of all paid consultants utilized in connection with the applicant's application for designation as a project:
"Name of Paid Consultant_____________
"Address___________________
"By signing below, I certify that all statements on or attached to this form are true and correct to the best of my knowledge.
"Signature:_____________________
"Date:_____________________
"Notary's Signature______________
"Date:____________________
"Notary Expires:_____________
Ala. Code § 45-51A-31.36 (1975)