FEC Form 1 for AMERICAN SOCIETY OF ANESTHESIOLOGISTS POLITICAL ACTION COMMITTEEForm 1 for AMERICAN SOCIETY OF ANESTHESIOLOGISTS POLITICAL ACTION COMMITTEE

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-134308

1. AMERICAN SOCIETY OF ANESTHESIOLOGISTS POLITICAL ACTION COMMITTEE

520 N. NORTHWEST HIGHWAY
PARK RIDGE, IL 60068
Fax: 8478251692
Email: R.BARWACZ@ASAHQ.ORG

2. Date: 09/10/2004

3. FEC Committee ID #: C00255752 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Custodian of Records:

RONALD BRUNS
520 N NORTHWEST HWY
PARK RIDGE, IL 60068
Title: EXECUTIVE DIRECTOR
Phone # (847) 825-5586

Treasurer:

RICHARD BARWACZ
520 N NORTHWEST HIGHWAY
PARK RIDGE, Illinois 60068
Title: DIRECTOR OF FINANCE
Phone # (847) 825-5586

Designated Agent(s):

Banks or Depositories

Signed: RICHARD BARWACZ
Date Signed: 09/10/2004
Official Committee FAX: 8478251692

(End FEC FORM 1)

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