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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1140148

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1. EmergeOrtho P.A. Political Action Committee

    NOTE:Commmittee Name is different than previously reported

    120 William Penn Plaza
    Durham, NC 27704
    Email: kbergquist@triangleortho.com;gsheasley@triangleortho.com

    NOTE: Email address is different than previously reported

2. Date: 01/20/2017

3. FEC Committee ID #: C00418582 This committee is a separate segregated fund. Its connected organization is a Membership Organization

Affiliated Committees/Organizations

EmergeOrtho PA
120 William Penn Plz
Durham, North Carolina 27704
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Kenneth W Bergquist
120 William Penn Plaza
Durham, NC 27704
Title: Treasurer
Phone # (919) 281-1810

Treasurer:

Kenneth W Bergquist
120 William Penn Plaza
Durham, North Carolina 27704
Title: Treasurer
Phone # (919) 281-1810

Designated Agent(s):

George Sheasley
120 William Penn Plaza
Durham, North Carolina 27704
Title: Asst Treasurer
Phone # (919) 281-1810

Banks or Depositories

Yadkin Bank
PO Box 888
Elkin, North Carolina 28621

Signed: Kenneth W Bergquist
Date Signed: 01/20/2017

(End FEC FORM 1)

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