FEC Form 1 for AMERICAN ASSOCIATION OF ORAL & MAXILLOFACIAL SURGEONS POLITICAL ACTION COMMITTEE (OMSPAC)Form 1 for AMERICAN ASSOCIATION OF ORAL & MAXILLOFACIAL SURGEONS POLITICAL ACTION COMMITTEE (OMSPAC)

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-16004

1. AMERICAN ASSOCIATION OF ORAL & MAXILLOFACIAL SURGEONS POLITICAL ACTION COMMITTEE (OMSPAC)

NOTE:Commmittee Name is different than previously reported

9700 WEST BRYN MAWR AVE
ROSEMONT, IL 60018
Email: michellel@aaoms.org

2. Date: 07/11/2001

3. FEC Committee ID #: C00005660 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

American Association of Oral and Maxillofacial Surgeons
9700 W. Bryn Mawr Ave
Rosemont, Illinois 60018
Relationship: Connected
Organization Type: Trade Association

Custodian of Records:

Ms Michelle Leiker, Esq.
9700 W. Bryn Mawr Ave.
Rosemont, IL 600185701
Title: Asst. Treasurer
Phone # (847) 233-4302

Treasurer:

Dr. Barry Stacey
5041 Dallas Hwy.
Bldg. 2 - Suite A
Powder Springs, Georgia 30127
Title: Treasurer
Phone # (770) 429-5507

Designated Agent(s):

Ms Carol O'Brien, Esq.
9700 W. Bryn Mawr Ave.
Rosemont, Illinois 60018
Title: Asst. Treasurer
Phone # (847) 233-4350

Ms Kathleen Connors
9700 W. Bryn Mawr Ave.
Rosemont, Illinois 60018
Title: Asst. Treasurer
Phone # (847) 233-4321

Ms Michelle Leiker, Esq.
9700 W. Bryn Mawr Ave.
Rosemont, Illinois 600185701
Title: Asst. Treasurer
Phone # (847) 233-4302

Banks or Depositories

Northern Trust Bank
8501 W. Higgins Rd.
Chicago, Illinois 60631

Zurich Money Market Account
Kemper Services Company
PO Box 219154
Kansas City, Missouri 641217197

Signed: Dr. Barry Stacey
Date Signed: 07/11/2001

(End FEC FORM 1)

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