ATTACHMENT A
Engineering Resources of Southern California Public Integrity Disclosure
PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principal Place of Business)
3. Local or California Address (if different than #2)
4. State where Entity is Registered with Secretary of State If other than California, is the Entity also registered in California? F Yes F No
5. Type of Entity
F Corporation F Limited Liability Company F Partnership F Trust F Other (please specify)
6. Officers, Directors, Members, Managers, Trustees, Other Fiduciaries (please specify) Note: If any response is not a natural person, please identify all officers, directors, members, managers and other fiduciaries for the member, manager, trust, or other entity
F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
FOther
F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
F Other
F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
F Other
Engineering Resources of Southern California, Inc.
1861 W. Redlands Blvd., Redlands, CA 92373
77-564 Country Club Drive, Suite 128, Palm Desert, CA 92211 California
John M. Brudin, PE, President
Moe Ahmadi, PE, Vice President
Trenton Brudin, PE, Secretary
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PUBLIC INTEGRITY DISCLOSURE
APPLICANT DISCLOSURE FORM
1. Name of Entity
2. Address of Entity (Principal Place of Business)
3. Local or California Address (if different than #2)
4. State where Entity is Registered with Secretary of State If other than California, is the Entity also registered in California? F Yes F No
5. Type of Entity
F Corporation F Limited Liability Company F Partnership F Trust F Other (please specify)
6. Officers, Directors, Members, Managers, Trustees, Other Fiduciaries (please specify) Note: If any response is not a natural person, please identify all officers, directors, members, managers and other fiduciaries for the member, manager, trust, or other entity
F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
FOther
F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
F Other
F Officer F Director F Member F Manager
[name] F General Partner F Limited Partner
F Other
Craig Brudin, QSP, Treasurer
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7. Owners/Investors with a 5% beneficial interest in the Applicant Entity or a related entity
EXAMPLE
JANE DOE
[name of owner/investor]
50%, ABC COMPANY, Inc.
[percentage of beneficial interest in entity and
name of entity]
A.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
B.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
C.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
D.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
E.
[name of owner/investor] [percentage of beneficial interest in entity and name of entity]
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
Signature of Disclosing Party, Printed Name, Title Date John M. Brudin, PE 65%
Moe Ahmadi, PE 15%
Trent Brudin, PE 10%
Craig Brudin, QSP 10%
October 16, 2024John M. Brudin, PE, President
g
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