%PDF-1.3
%
1 0 obj
<<
/Producer (OmniForm Converter for PDF)
/Creator (OmniForm Premium)
>>
endobj
4 0 obj
[ /PDF /Text ]
endobj
6 0 obj
<< /Length 7 0 R >>
stream
BT
/F0 10 Tf
0 g 451.55 758.628 Td 95 Tz (REQUEST NUMBER:) Tj
-195.735 -26.81 Td 100 Tz (CITY OF CHICAGO) Tj
0 -11.472 Td (OFFICE OF EMERGENCY MANAGEMENT & COMMUNICATIONS) Tj
0 -11.472 Td (PRIVILEGED AND CONFIDENTIAL) Tj
0 -2.146 Td 136.766 -17.456 Td 104 Tz (REQUEST DATE:) Tj
-364.170 -13.204 Td 97 Tz (TO: OEMC KEEPER OF RECORDS) Tj
277.109 -0.482 Td 94 Tz (FROM:) Tj
0 -21.838 Td 97 Tz (DEPARTMENT/AGENCY:) Tj
-245.52 -25.682 Td 106 Tz (PROVIDE ALL INFORMATION BELOW. COMPLETE A SEPARATE FORM FOR EACH INCIDENT) Tj
-32.187 -19.675 Td 95 Tz (DATE OF INCIDENT:) Tj
230.187 0.363 Td (LOCATION OF INCIDENT:) Tj
-118.704 -0.003 Td (TIME OF INCIDENT:) Tj
293.182 0.967 Td (TYPE OF INCIDENT:) Tj
-405.391 -35.983 Td (CHICAGO POLICE DEPT. RD # AND/OR EVENT #) Tj
252.388 0.003 Td 94 Tz (REASON FOR REQUEST \(CASE/CR/U/EO/SPAR/LOG NUMBER\):) Tj
-251.787 -35.376 Td 95 Tz (ADDITIONAL COMMENTS / INFORMATION:) Tj
1.443 -88.960 Td (MATERIALS REQUESTED:) Tj
286.228 -28.695 Td 96 Tz (POD/ OVS CAMERA VIDEO) Tj
-239.04 0 Td 95 Tz (AUDIO OF 911 CALLS) Tj
0.24 -14.159 Td (CPD RADIO TRANSMISSIONS) Tj
239.04 0 Td 106 Tz (GPS DATA) Tj
0 -13.92 Td 94 Tz (PDT MESSAGES \(INDICATE UNITS OR PDT # ABOVE\)) Tj
-238.802 -0.479 Td 95 Tz (CFD RADIO TRANSMISSIONS) Tj
0 -14.159 Td (CAD EVENT QUERIES / UNIT HISTORY) Tj
239.04 -0.24 Td 89 Tz (OTHER \(SPECIFY\):) Tj
-60.117 -26.515 Td 95 Tz (REQUESTER SIGNATURE:) Tj
-227.313 0.125 Td 91 Tz (REQUESTER NAME \(PRINT\)) Tj
183.512 0.357 Td 93 Tz (RANK:) Tj
201.39 -29.648 Td 96 Tz (PAX/MARSHAL#) Tj
-157.952 0 Td 94 Tz (TELEPHONE #:) Tj
-43.438 -0.238 Td 95 Tz (UNIT) Tj
-183.271 0 Td 99 Tz (STAR/EMPLOYEE/BADGE #:) Tj
274.966 -33.956 Td 94 Tz (SIGNATURE:) Tj
-275.326 -1.443 Td 96 Tz (DEPUTY / WATCH COMMANDER/ DIRECTOR/) Tj
0.479 -11.04 Td 92 Tz (CORPORATION COUNSEL NAME \(PRINT\):) Tj
-0.706 -30.33 Td 104 Tz (FAX REQUESTS TO:) Tj
/F0 9 Tf
108.947 -19.905 Td 100 Tz (CFD AUDIO AND CAD AND ALL OTHER REQUESTS: \(312\) 746-9333) Tj
1.593 -14.57 Td (PDT MESSAGES AND VIDEO: \(312\)746-9202) Tj
-2.769 -12.246 Td (CPD AUDIO, CAD, GPS DATA: \(312\)746-9154 EMERGENCY AFTER-HOURS \(312\)746-9335) Tj
/F1 9 Tf
-101.778 -16.146 Td (FOR OEMC USE ONLY) Tj
ET
1 w
0 G
2 J
27.918 691.424 207.371 65.123 re
S
BT
/F0 10 Tf
29.186 59.142 Td (FORM:OEMC-109 \(REV. 4/13\)) Tj
ET
0 J
26.478 685.477 m
575.892 685.480 l
S
0 J
27.626 648.822 m
576.445 649.426 l
S
0 J
302.091 685.477 m
302.091 648.765 l
S
0 J
449.524 769.136 m
449.524 733.626 l
S
0 J
571.632 768.586 m
571.632 733.68 l
S
0 J
450.125 734.224 m
572.28 734.224 l
S
0 J
448.869 768.583 m
572.227 768.583 l
S
BT
256.507 694.814 Td (MEDIA/DATA REQUEST) Tj
ET
0 J
26.977 619.387 m
576.391 619.390 l
S
0 J
26.92 584.538 m
575.736 584.54 l
S
0 J
136 619.274 m
136.602 584.969 l
S
0 J
255.699 619.33 m
256.3 585.026 l
S
0 J
429.559 618.783 m
430.16 584.478 l
S
0 J
276.707 584.481 m
276.707 550.78 l
S
0 J
26.870 550.290 m
575.685 550.293 l
S
0 J
26.816 460.072 m
575.632 460.074 l
S
0 J
27.363 361.426 m
576.179 361.429 l
S
0 J
27.910 331.390 m
576.726 331.393 l
S
0 J
27.255 297.743 m
576.07 297.746 l
S
0 J
208.814 362.296 m
209.415 298.502 l
S
0 J
252.692 361.749 m
253.293 297.955 l
S
0 J
411.506 331.71 m
411.506 298.006 l
S
0 J
27.201 255.67 m
576.017 255.674 l
S
0 J
301.929 298.063 m
301.929 255.33 l
S
0 J
26.478 686.078 m
26.478 255.172 l
S
0 J
575.841 686.132 m
575.841 255.226 l
S
2 w
0 J
28.352 69.763 m
577.168 69.766 l
S
1 w
0 J
296.668 428.499 m
305.099 428.496 l
S
0 J
296.614 418.918 m
306.244 418.317 l
S
0 J
297.272 427.895 m
297.272 418.867 l
S
0 J
306.247 429.157 m
306.244 419.528 l
S
2 J
1 g
56.568 418.297 9 9 re
B
2 J
56.568 405.658 9 9 re
B
2 J
56.565 392.417 9 9 re
B
2 J
56.565 378.575 9 9 re
B
2 J
297.275 405.060 9 9 re
B
2 J
297.275 390.01 9 9 re
B
2 J
297.275 376.166 9 9 re
B
2 J
575.524 365.848 m
403.44 365.848 l
S
BT
0 g 39.6 154.548 Td 95 Tz (APPROVED FOR RELEASE) Tj
ET
.50 w
2 J
337.198 169.679 m
337.198 145.919 l
S
BT
212.4 159.347 Td 93 Tz (DATE:) Tj
130.32 -4.799 Td 94 Tz (SIGNATURE:) Tj
-303.12 -23.519 Td (PREPARED BY:) Tj
ET
2 J
337.198 145.919 m
337.198 122.4 l
S
BT
213.352 134.637 Td (DATE PREPARED:) Tj
-139.192 -30.01 Td 95 Tz (MAIL DELIVERY) Tj
ET
2 J
337.198 122.4 m
337.198 96.48 l
S
BT
212.4 112.068 Td 94 Tz (DATE SENT:) Tj
130.32 -6 Td 91 Tz (VIA:) Tj
-268.56 -27.598 Td 95 Tz (PICK UP) Tj
ET
2 J
337.198 96.48 m
337.198 70.56 l
S
BT
212.749 85.2 Td (DATE PICKED UP:) Tj
130.212 -5.054 Td 94 Tz (RECEIVED BY:) Tj
ET
2 J
34.319 70.56 542.4 99.119 re
S
0 J
34.319 145.919 m
576.72 145.919 l
S
0 J
34.319 122.4 m
576.72 122.4 l
S
0 J
34.319 96.48 m
576.72 96.48 l
S
0 J
211.439 169.679 m
211.439 70.56 l
S
0 J
337.2 169.679 m
337.2 70.56 l
S
endstream
endobj
7 0 obj
4666
endobj
5 0 obj
<<
/Type /Page
/Parent 3 0 R
/Resources << /ProcSet [ /PDF /Text ] /Font << /F0 8 0 R /F1 11 0 R >> >>
/MediaBox [ 0 0 612 792 ]
/Contents 6 0 R
/Annots 50 0 R
>>
endobj
14 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 450 736 570 749 ]
/T (FillText3)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
18 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 479 686 574 699 ]
/T (FillText2)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
19 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 28 649 298 675 ]
/T (FillText1)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
/Ff 4096
>>
endobj
20 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 426 650 576 685 ]
/T (DEPARTMENT_AGENCY_FROM)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
/Ff 4096
>>
endobj
21 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 26 585 135 599 ]
/T (FillText4)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
22 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 138 585 254 599 ]
/T (FillText5)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
23 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 257 585 428 599 ]
/T (FillText6)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
24 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 431 586 576 599 ]
/T (FillText7)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
25 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 28 551 274 564 ]
/T (FillText8)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
26 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 278 551 574 565 ]
/T (FillText9)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
27 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 28 460 574 536 ]
/T (FillText10)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
/Ff 4096
>>
endobj
28 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 57 418 66 427 ]
/FT /Btn
/H /T
/T (CheckBox1)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 53 0 R /Off 54 0 R >>
/D << /1 53 0 R /Off 54 0 R >>
>>
>>
endobj
53 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
54 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
29 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 57 406 66 415 ]
/FT /Btn
/H /T
/T (CheckBox2)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 55 0 R /Off 56 0 R >>
/D << /1 55 0 R /Off 56 0 R >>
>>
>>
endobj
55 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
56 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
30 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 57 392 66 401 ]
/FT /Btn
/H /T
/T (CheckBox3)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 57 0 R /Off 58 0 R >>
/D << /1 57 0 R /Off 58 0 R >>
>>
>>
endobj
57 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
58 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
31 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 57 379 66 388 ]
/FT /Btn
/H /T
/T (CheckBox4)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 59 0 R /Off 60 0 R >>
/D << /1 59 0 R /Off 60 0 R >>
>>
>>
endobj
59 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
60 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
32 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 297 405 306 414 ]
/FT /Btn
/H /T
/T (CheckBox6)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 61 0 R /Off 62 0 R >>
/D << /1 61 0 R /Off 62 0 R >>
>>
>>
endobj
61 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
62 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
33 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 297 390 306 399 ]
/FT /Btn
/H /T
/T (CheckBox7)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 63 0 R /Off 64 0 R >>
/D << /1 63 0 R /Off 64 0 R >>
>>
>>
endobj
63 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
64 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
34 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 297 376 306 385 ]
/FT /Btn
/H /T
/T (CheckBox8)
/F 4
/AS /Off
/DA (0 g /ZaDb 11 Tf)
/AP
<<
/N << /1 65 0 R /Off 66 0 R >>
/D << /1 65 0 R /Off 66 0 R >>
>>
>>
endobj
65 0 obj
<<
/Resources << /ProcSet [/PDF /Text] /Font << /ZaDb 52 0 R >> >>
/BBox [ 0 0 9 9 ]
/MK << /CA (8) >>
/Length 54
>>
stream
BT 0 g /ZaDb 11 Tf 1 0 0 1 0.774 0.694 Tm (8) Tj
ET
endstream
endobj
66 0 obj
<<
/Resources << /ProcSet [/PDF] >>
/BBox [ 0 0 9 9 ]
/Length 3
>>
stream
0 G
endstream
endobj
35 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 403 366 576 379 ]
/T (OTHER_SPECIFY)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
36 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 28 333 206 347 ]
/T (FillText11)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
37 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 210 333 251 347 ]
/T (FillText12)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
38 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 27 301 206 314 ]
/T (FillText14)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
39 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 210 301 251 315 ]
/T (FillText15)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
40 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 255 300 407 314 ]
/T (FillText16)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
41 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 413 300 575 314 ]
/T (FillText17)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
42 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 29 258 300 271 ]
/T (FillText18)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
43 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 213 146 337 159 ]
/T (DATE)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
44 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 112 122 211 136 ]
/T (PREPARED_BY)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
45 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 212 122 337 136 ]
/T (DATE_PREPARED)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
46 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 212 96 337 110 ]
/T (DATESENT)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
47 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 365 96 577 110 ]
/T (VIA)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
48 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 213 71 337 84 ]
/T (DATE_PICKED_UP)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
49 0 obj
<<
/Type /Annot
/Subtype /Widget
/Rect [ 413 71 577 84 ]
/T (RECEIVED_BY)
/FT /Tx
/DA (/TiRo 10 Tf 0 g)
/Maxlen 16000
/F 4
>>
endobj
50 0 obj
[
14 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R
25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R
33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R
41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R
49 0 R
]
endobj
67 0 obj
<<
/AcroForm 0.8
/DR 68 0 R
/DA (/TiRo 10 Tf 0 g)
/Fields
[
14 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R
25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R
33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R
41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R
49 0 R
]
>>
endobj
68 0 obj
<<
/Font << /TiRo 51 0 R /ZaDb 52 0 R >>
>>
endobj
51 0 obj
<<
/Type /Font
/Subtype /Type1
/Name /TiRo
/BaseFont /Times-Roman
/FirstChar 32
/LastChar 255
/Encoding 69 0 R
>>
endobj
52 0 obj
<<
/Type /Font
/Subtype /Type1
/Name /ZaDb
/BaseFont /ZapfDingbats
/FirstChar 32
/LastChar 255
>>
endobj
69 0 obj
<<
/Type /Encoding
/Differences [
24 /breve /caron /circumflex /dotaccent /hungarumlaut /ogonek /ring
/tilde 39 /quotesingle 96 /grave 128 /bullet /dagger /daggerdbl
/ellipsis /emdash /endash /florin /fraction /guilsinglleft /guilsinglright
/minus /perthousand /quotedblbase /quotedblleft /quotedblright /quoteleft
/quoteright /quotesinglbase /trademark /fi /fl /Lslash /OE /Scaron
/Ydieresis /Zcaron /dotlessi /lslash /oe /scaron /zcaron 160 /Euro
164 /currency 166 /brokenbar 168 /dieresis /copyright /ordfeminine
172 /logicalnot /.notdef /registered /macron /degree /plusminus
/twosuperior /threesuperior /acute /mu 183 /periodcentered /cedilla
/onesuperior /ordmasculine 188 /onequarter /onehalf /threequarters
192 /Agrave /Aacute /Acircumflex /Atilde /Adieresis /Aring /AE /Ccedilla
/Egrave /Eacute /Ecircumflex /Edieresis /Igrave /Iacute /Icircumflex
/Idieresis /Eth /Ntilde /Ograve /Oacute /Ocircumflex /Otilde /Odieresis
/multiply /Oslash /Ugrave /Uacute /Ucircumflex /Udieresis /Yacute
/Thorn /germandbls /agrave /aacute /acircumflex /atilde /adieresis
/aring /ae /ccedilla /egrave /eacute /ecircumflex /edieresis /igrave
/iacute /icircumflex /idieresis /eth /ntilde /ograve /oacute /ocircumflex
/otilde /odieresis /divide /oslash /ugrave /uacute /ucircumflex
/udieresis /yacute /thorn /ydieresis
]
>>
endobj
8 0 obj
<<
/Type /Font
/Subtype /TrueType
/Name /F0
/BaseFont /TimesNewRoman,Bold
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 9 0 R
/Widths 10 0 R
>>
endobj
9 0 obj
<<
/Type /FontDescriptor
/Flags 34
/FontName /TimesNewRoman,Bold
/FontBBox [ -558 -307 2000 1026 ]
/MissingWidth 778
/StemV 85
/StemH 85
/ItalicAngle 0
/CapHeight 891
/XHeight 623
/Ascent 891
/Descent -216
/Leading 149
/MaxWidth 2558
/AvgWidth 427
>>
endobj
10 0 obj
[
778 778 250 333 555 500 500 1000 833 278 333 333 500 570 250 333
250 278 500 500 500 500 500 500 500 500 500 500 333 333 570 570
570 500 930 722 667 722 722 667 611 778 778 389 500 778 667 944
722 778 611 778 722 556 667 722 722 1000 722 722 667 333 278 333
581 500 333 500 556 444 556 444 333 500 556 278 333 556 278 833
556 500 556 556 444 389 333 556 500 722 500 500 444 394 220 394
520 778 500 778 333 500 500 1000 500 500 333 1000 556 333 1000 778
667 778 778 333 333 500 500 350 500 1000 333 1000 389 333 722 778
444 722 250 333 500 500 500 500 220 500 333 747 300 500 570 333
747 500 400 549 300 300 333 576 540 250 333 300 330 500 750 750
750 500 722 722 722 722 722 722 1000 722 667 667 667 667 389 389
389 389 722 722 778 778 778 778 778 570 778 722 722 722 722 722
611 556 500 500 500 500 500 500 722 444 444 444 444 444 278 278
278 278 500 556 500 500 500 500 500 549 500 556 556 556 556 500
556 500
]
endobj
11 0 obj
<<
/Type /Font
/Subtype /TrueType
/Name /F1
/BaseFont /TimesNewRoman,BoldItalic
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 12 0 R
/Widths 13 0 R
>>
endobj
12 0 obj
<<
/Type /FontDescriptor
/Flags 290
/FontName /TimesNewRoman,BoldItalic
/FontBBox [ -547 -307 1206 1032 ]
/MissingWidth 778
/StemV 85
/StemH 85
/ItalicAngle -16
/CapHeight 891
/XHeight 623
/Ascent 891
/Descent -216
/Leading 149
/MaxWidth 1753
/AvgWidth 412
>>
endobj
13 0 obj
[
778 778 250 389 555 500 500 833 778 278 333 333 500 570 250 333
250 278 500 500 500 500 500 500 500 500 500 500 333 333 570 570
570 500 832 667 667 667 722 667 667 722 778 389 500 667 611 889
722 722 611 722 667 556 611 722 667 889 667 611 611 333 278 333
570 500 333 500 500 444 500 444 333 500 556 278 278 500 278 778
556 500 500 500 389 389 278 556 444 667 500 444 389 348 220 348
570 778 500 778 333 500 500 1000 500 500 333 1000 556 333 944 778
611 778 778 333 333 500 500 350 500 1000 333 1000 389 333 722 778
389 611 250 389 500 500 500 500 220 500 333 747 266 500 606 333
747 500 400 549 300 300 333 576 500 250 333 300 300 500 750 750
750 500 667 667 667 667 667 667 944 667 667 667 667 667 389 389
389 389 722 722 722 722 722 722 722 570 722 722 722 722 722 611
611 500 500 500 500 500 500 500 722 444 444 444 444 444 278 278
278 278 500 556 500 500 500 500 500 549 500 556 556 556 556 444
500 444
]
endobj
15 0 obj
<<
/Type /Font
/Subtype /TrueType
/Name /F2
/BaseFont /TimesNewRoman
/FirstChar 30
/LastChar 255
/Encoding /WinAnsiEncoding
/FontDescriptor 16 0 R
/Widths 17 0 R
>>
endobj
16 0 obj
<<
/Type /FontDescriptor
/Flags 34
/FontName /TimesNewRoman
/FontBBox [ -568 -307 2000 1007 ]
/MissingWidth 778
/StemV 85
/StemH 85
/ItalicAngle 0
/CapHeight 891
/XHeight 623
/Ascent 891
/Descent -216
/Leading 149
/MaxWidth 2568
/AvgWidth 401
>>
endobj
17 0 obj
[
778 778 250 333 408 500 500 833 778 180 333 333 500 564 250 333
250 278 500 500 500 500 500 500 500 500 500 500 278 278 564 564
564 444 921 722 667 667 722 611 556 722 722 333 389 722 611 889
722 722 556 722 667 556 611 722 722 944 722 722 611 333 278 333
469 500 333 444 500 444 500 444 333 500 500 278 278 500 278 778
500 500 500 500 333 389 278 500 500 722 500 500 444 480 200 480
541 778 500 778 333 500 444 1000 500 500 333 1000 556 333 889 778
611 778 778 333 333 444 444 350 500 1000 333 980 389 333 722 778
444 722 250 333 500 500 500 500 200 500 333 760 276 500 564 333
760 500 400 549 300 300 333 576 453 250 333 300 310 500 750 750
750 444 722 722 722 722 722 722 889 667 611 611 611 611 333 333
333 333 722 722 722 722 722 722 722 564 722 722 722 722 722 722
556 500 444 444 444 444 444 444 667 444 444 444 444 444 278 278
278 278 500 500 500 500 500 500 500 549 500 500 500 500 500 500
500 500
]
endobj
3 0 obj
<<
/Type /Pages
/Count 1
/Kids [ 5 0 R ]
/MediaBox [ 0 0 612 792 ]
>>
endobj
2 0 obj
<<
/Type /Catalog
/Pages 3 0 R
/AcroForm 67 0 R
>>
endobj
xref
0 70
0000000000 65535 f
0000000015 00000 n
0000019000 00000 n
0000018912 00000 n
0000000103 00000 n
0000004874 00000 n
0000000134 00000 n
0000004853 00000 n
0000014713 00000 n
0000014898 00000 n
0000015165 00000 n
0000016112 00000 n
0000016305 00000 n
0000016582 00000 n
0000005052 00000 n
0000017525 00000 n
0000017707 00000 n
0000017970 00000 n
0000005195 00000 n
0000005338 00000 n
0000005489 00000 n
0000005654 00000 n
0000005796 00000 n
0000005939 00000 n
0000006082 00000 n
0000006225 00000 n
0000006367 00000 n
0000006510 00000 n
0000006662 00000 n
0000007189 00000 n
0000007716 00000 n
0000008243 00000 n
0000008770 00000 n
0000009299 00000 n
0000009828 00000 n
0000010357 00000 n
0000010504 00000 n
0000010647 00000 n
0000010791 00000 n
0000010934 00000 n
0000011078 00000 n
0000011222 00000 n
0000011366 00000 n
0000011509 00000 n
0000011647 00000 n
0000011792 00000 n
0000011939 00000 n
0000012080 00000 n
0000012216 00000 n
0000012362 00000 n
0000012505 00000 n
0000013139 00000 n
0000013270 00000 n
0000006877 00000 n
0000007083 00000 n
0000007404 00000 n
0000007610 00000 n
0000007931 00000 n
0000008137 00000 n
0000008458 00000 n
0000008664 00000 n
0000008987 00000 n
0000009193 00000 n
0000009516 00000 n
0000009722 00000 n
0000010045 00000 n
0000010251 00000 n
0000012761 00000 n
0000013078 00000 n
0000013385 00000 n
trailer
<<
/Size 70
/Root 2 0 R
/Info 1 0 R
>>
startxref
19071
%%EOF1 0 obj
<>
endobj
2 0 obj
<>
endobj
28 0 obj
<>/N<1 53 0 R/Off 54 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[57 418 66 427]/Subtype/Widget/T(CheckBox1)/Type/Annot>>
endobj
29 0 obj
<>/N<1 55 0 R/Off 56 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[57 406 66 415]/Subtype/Widget/T(CheckBox2)/Type/Annot>>
endobj
30 0 obj
<>/N<1 57 0 R/Off 58 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[57 392 66 401]/Subtype/Widget/T(CheckBox3)/Type/Annot>>
endobj
31 0 obj
<>/N<1 59 0 R/Off 60 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[57 379 66 388]/Subtype/Widget/T(CheckBox4)/Type/Annot>>
endobj
32 0 obj
<>/N<1 61 0 R/Off 62 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[297 405 306 414]/Subtype/Widget/T(CheckBox6)/Type/Annot>>
endobj
33 0 obj
<>/N<1 63 0 R/Off 64 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[297 390 306 399]/Subtype/Widget/T(CheckBox7)/Type/Annot>>
endobj
34 0 obj
<>/N<1 65 0 R/Off 66 0 R>>>>/AS/Off/DA(0 g /ZaDb 11 Tf)/F 4/FT/Btn/H/T/P 5 0 R/Rect[297 376 306 385]/Subtype/Widget/T(CheckBox8)/Type/Annot>>
endobj
50 0 obj
[14 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 71 0 R 72 0 R]
endobj
67 0 obj
<>
endobj
68 0 obj
<>/Font<>>>
endobj
70 0 obj
<>stream
OmniForm Premium
2013-06-11T08:38:01-05:00
2013-06-11T08:38:01-05:00
2013-06-11T08:38:01-05:00
OmniForm Converter for PDF
application/pdf
uuid:7dd18a77-2fd2-43b9-9a37-a12632be6052
uuid:8a6bf956-d43c-4917-a290-3b060b93aef1
endstream
endobj
71 0 obj
<>/C[1.0 0.0 0.0]/CreationDate(D:20130604144521-05'00')/F 4/M(D:20130611083743-05'00')/NM(3wM1KXFExXZo3XSBrL5LCA)/Name/#23clipboard/P 5 0 R/Popup 72 0 R/Rect[22.3766 690.686 241.524 768.507]/Subj(Placed Image)/Subtype/Stamp/T(Mike Kap)/Type/Annot>>
endobj
72 0 obj
<>
endobj
73 0 obj
<>>>/Subtype/Form/Type/XObject>>stream
597 0 0 212 0 0 cm
/Icon Do
endstream
endobj
74 0 obj
<>stream
HSCr'IcMv:Qal3S N3fDK9/J($%vj@(Z "`_@QRؽw?w{{Acuoo> >}x{cP5]^Zl&vFW&{ <"vK֧{CqcO}̼H ًWWwn;6~c
/Xڎ>CcT#`f