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FEC Form 1 for AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PACForm 1 for AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-746097


1. AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIAN PAC

    2831 Lone Oak Road
    Paducah, KY 42003
    Email: paula@thepainmd.com

    NOTE: Email address is different than previously reported

2. Date: 09/22/2011

3. FEC Committee ID #: C00351197 This committee is a separate segregated fund. Its connected organization is a Membership Organization

Affiliated Committees/Organizations

American Society of International Pain Physicians
2831 Lone Oak Road
Paducha, Kentucky 42003
Affiliated Relationship Code: Connected Organization

Custodian of Records:


Treasurer:

Laxmaiah Manchikanti
2075 Natchez Lane
Paducah, Kentucky 42001
Title: Treasurer
Phone # (270) 554-8373

Designated Agent(s):

Yogesh Malla
6510 Tuscan Road
Paducah, Kentucky 42003
Title: Assistant Tresurer
Phone # (270) 554-8373

Banks or Depositories

Bantera Bank
3151 Jackson Street
Paducah, Kentucky 42003

Signed: Laxmaiah Manchikanti
Date Signed: 09/22/2011

(End FEC FORM 1)


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