RECORD OF REQUEST FOR PURCHASE OF POLITICAL TIME
CANDIDATE OR ISSUE
COMPLETED FORM TO BE SENTA TIME OF ORDER AND WILL BE PLACED IN PUBLIC INSPECTION FILE)

1. Date of Request: 3: 2. Requester: a. Bind
3. Address of Person making the Request: DOE: 1:2- ESIBAM 3+ "?4930 ??36\68 I CA

4. Telephone Number of Person making the request: 

5. CANDIDATE ADS:

Name of Candidate:

 

Name of Candidate's Authorized Committee:

 

Name of Treasurer of Candidate?s Committee:

 

Legally Qualified Candidate for Office of

 

 

Election: A1TACH REQUESTED SCHEDULE OF 
PRIMARY ELECTION Democrat Republican Other
GENERAL ELECTION Democrat Republican Other
CAUCUS Democrat Republican Other

 

6. ADs:

Name of Organization Buying Time: NOW

Issue of National Importance: Yes

EesErib-e Content of Issue Ad (complete 5 above if a Candidate is gendene?i 1M): 
Names gig-d Agresses of Chief Executive Of?cers, Exeajtive Cona??ie or Board of 

7. If advertisement relates to a candidate running for election:

Name of Candidate:
Candidate?s Party Af?liation:
Office Sought by Candidate: I

 

 

8. Request to Purchase Time: ACCEPTED IN WHOLE ACCEPTED IN PART REIECTED

9. Interconnect (Y or 

Zonesh?m 339? CLAW

10. If request to purchase time is ACCEPTED (in whole or in part) from Candidate or from an issue/advocacy advertiser and
the advertisement relates to an issue of national im ortance attach a copy of the Insertion Order (including schedule of
time purchased, rates charged, class of time purchased), (ii) Invoice, and Af?davit of Performance indicating dates and
times the advertisement aired and place in the Political File. If request to purchase time is ACCEPTED (in whole or in part)

from an issue/advocacy advertiser and the advertisement relates to all other political issues place only the Record of
Request in the Political File.

 

 

 

Signed: Date: 16? 

Name:
PositionL
end 3 OR to comcast. com when you submit an order