FEC Form 1 for Providence Anesthesiology Associates PA Fed PACForm 1 for Providence Anesthesiology Associates PA Fed PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1319758

1. Providence Anesthesiology Associates PA Fed PAC

5910 Providence Country Club Drive
Charlotte, NC 28277
Email: freemanjackson@gmail.com;karenrusak@gmail.com

NOTE: Email address is different than previously reported

2. Date: 03/18/2019

3. FEC Committee ID #: C00664664 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Providence Anesthesiology Associates, PA
131 Providence Road, Suite 200
Charlotte, North Carolina 28207
Affiliated Relationship Code: Connected Organization

Custodian of Records:

Treasurer:

Dr. Freeman Jackson
2533 Chesterfield Avenue
Charlotte, North Carolina 28205
Title: Treasurer
Phone # (336) 609-1030

Designated Agent(s):

Dr. John Ebert
5910 Providence Country Club Drive
Charlotte, North Carolina 28277

Banks or Depositories

Branch Bank and Trust
5369 Ballantyne Commons Parkway
Charlotte, North Carolina 28277

Signed: Dr. John Ebert
Date Signed: 03/18/2019

(End FEC FORM 1)

Generated Mon Aug 19 12:05:17 2024