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~.a na laaze i nzentlo n .,~, ............ <br /> ZD q2~ ~,'7q <br /> Check One: [] lnmal [] Amendment ~ Termination <br /> I Candidate Information o.~ceu~only <br /> FULL ~ME OF ~MDIDATE (~ST, ~,~T. MIDDY) ~ <br /> ADD.SS (N~ AND ST~E~ / A~A CODE~AYTIME PHONE <br /> <br /> ZIP [00[ <br /> <br /> II Office Sought <br /> <br /> PUBLIC AGENCY NAME TYII~ 0~: <br /> (Check One if Appticat>le) [] Special [] Recall <br /> <br /> JURISDICTION OF ELECTIVE OFFICE SOUGHT (Checlc One) <br /> <br /> [] State [] County of <br /> [] Multi-County [] City of <br /> <br /> III Verification <br /> I certify under penalty of perjury under the laws ot the State of California that the torego,ng ,s true and <br /> <br /> % DATE ' CITY AND S~ATE ~ J SIGNATURE O~ CANOIDATE <br /> <br />~T~ FOdlI11~FC~LI;UVIR[~TIOoi~ R2C~Q?IREO TO BE PRO¥1DED TO YOU PURSUANT TO THE INFORMATION PRACTICES ACT OF 1977. SEE INFORMATION MANUAL A ON CAMPAIGN DISCLOSURE Pt~OVISIONS 0F THE <br />State of California Fair Political Practices Commission. <br /> <br /> Campaign Ban k Account Type or Print in Ink. CAMPAIGN BANK ACCT. <br /> <br /> Check One: [] Inrtial [] Redesignate the Account for Future Election to the Same Office <br /> [] Amendment [~ Termination (Note: In addition, file a Form 501 if you are no longer <br /> soliciting or receiving contributions.) <br /> Office Use 0nly <br /> <br /> ~ I Candidate Information <br /> FULL IIA/~ OF CMIDIDATE tLAST. FIIIST. Maxx~ <br /> <br /> AOORES$ ~L ~0. A~O STREE~ ~ COOFdOAYTIME PHONE <br /> <br /> CITY STATE ZIP CODE YEAII Off: ELEcnoII <br /> <br /> OI:FICE SOU~tffl' AND AGENCY IIAME <br /> <br /> ~-~ II Account Informtion <br /> <br /> AOORIESS ~10. ANO STREET) AREA COO~d~IO~E NUld~ER ' D~I'E <br /> <br /> III Verification <br /> , , . I certifi/under penalty of perjury under the laws of the State of California that the foregoing i~rue and correct. <br /> <br /> CITY AND STATE SIGNATURE Of CANDIDATE <br /> <br /> FOI~ II~OR~,IlON REQUIRED TO B~ PROVIOED TO YOU PURSUANT TO TH~ II~ORMATION PRACTICES ACT Of 1977, SEE INFORMATION MANUAL A ON CAMPAIGN DISC~OSUI~ PROVISIONS OF THE <br /> POLITICAL REFOILM ACT. g4 ~ <br /> State of California Fair Politkal Practices Commission. <br /> <br /> <br />