BARBARA K.

CEGAVSKE State of Nevada

Secretary of State
Committee Registration Form
101 North Carson Street, Suite 3
Use this form to register or make changes to a:
Carson City, Nevada 89701
• Committee for Political Action (PAC)
(775) 684-5705
• Committee for Political Action (PAC) Advocating Passage or Defeat
Facsimile: (775) 684-5718 of a Ballot Question
Email: nvelect@sos.nv.gov • Committee Sponsored by a Political Party
Website: www.nvsos.gov • Recall Committee

1!J Committee for Political Action (PAC) D Committee Sponsored by a Political Party D Recall Committee

D Committee for Political Action (PAC) Advocating Passage

~~iori·:~eq11~~ted
·s:tea1a11't11at·a •· ·,
D New Registration D PAC Annual Registration (Due on or before January 15th of each year- NRS 294A.230(4)(b))

~ Amended Registration (check all that apply):

D Change Officers D Change Registered Agent D Change Address D Reactivation
D Change Name (previous name of Committee)

l!J Other
PHONE NUMBER
Name of Committee
1864 PAC
Mailing Address City State ZIP Code
PO BOX 10904 RENO NV 89510
Email Address Telephone Number
1864PAC@GMAIL.COM (775) 583-5565
PUPROSE: Briefly state the purpose for which the Committee was organized.

POLITICAL ACTION AND EDUCTION

Name of Public Officer to be Recalled (Include title of office held) *This section only applies to a Recall Committee*

REGISTERED AGENT: Pursuant to NRS 294A.240, each PAC must appoint and keep In the State a registered agent, as provided In
NRS 14.020, who must be a natural person who resides In the State of Nevada.
•Recall Committees only need a Registered Agent If it is on organization located outside the State.•
Name of Registered Agent Email Address Telephone Number
CORY HENDERSON 1864PAC@GMAIL.COM (775) 583-5565
Physical Address City State ZIP Code
5355 KIETZKE LANE #200 RENO NV 89511

(£ \..]/' .-
R~TER"fG~N~ ACCEPTANCE: I hereby accept appointment as Registered Agent for the above-named Committee.
For Office Use Only

Signature of Registered Agent Office of the KRhynes

Secretary of State
04/26/2022 4/26/22 #9126
Date
Barbara Cegavske
Elections Division
EL400
Revised: 02-05-2019
Page 1 of2
 OFFICERS: Li~t the name, title, address and telephone number of each officer (attach .additional pages, if necessary).

Officer Name and Title Telephone Number

CORY HENDERSON, PRESIDENT (775) 583-5565
Mailing Address IRENO
City State IZIP Code
PO BOX 10904 NV 89510
Officer Name and Title Telephone Number

Mailing Address I City State IZIP Code

Officer Name and Title Telephone Number

Mailing Address I City State IZIP Code

Officer Name and Title Telephone Number

Mailing Address I City State IZIP Code

~~•~~J"fqN§,:' l,f ttt,e P~C 1,, ~l!~_ecl ~ any 9~f 0111anlzatlons, list the narne, address and telephone number of each
o-'-''1i'i~on'(attachacldltionaf'·""-es/lf
...~,..,.... , ,,.... .. ' .....,.... .. ,·-.- .•. ~ . . necessa
. _ry). "'
•tioiiilail Party Committees and Recoil Committees may skip this section.• '
Name of Organization Telephone Number

Mailing Address I City State I ZIP Code

Name of Organization Telephone Number

Mailing Address I City State IZIP Code

SUBMITTED BY:

CORY HENDERSON (775} 583-5565

Printed N a ~ / Telephone Number

04/26/2022
s~ Date

EL400
Revised: 02-05-2019

Page 2 of2