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FORM 1 STATEMENT OF 2005 Please print or type your name, mailing address, agency name, and position below: FINANCIAL INTERESTS LAST NAME FIRST NAME MIDDLE NAME : FOR OFFICE USE ONLY: Surgeon Mark
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Spurgeon Mark Andrew is a fictitious name made up for the purpose of this example.
Any individual or entity required to file this form based on the specific regulations of their jurisdiction.
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The purpose of this form is to collect and report specific information to the appropriate regulatory authorities.
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