New York > Secretary Of State > Blue Sky > Investor Protection And Securities
Broker Dealer Statement M-1 - New York
| Broker Dealer Statement Form. This is a New York form and can be used in Investor Protection And Securities Blue Sky Secretary Of State . |
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NEW YORK STATE DEPARTMENT OF LAW INVESTOR PROTECTION BUREAU 120 Broadway, 23rd Floor New York, NY 10271-0332 1-800-771-7755 TDD (for hearing impaired) 1-800-788-9898 www.oag.state.ny.us BROKER/DEALER STATEMENT (Section 359-e General Business Law) Type of filing: New/Original Renewal NY FORM M-1 File Number _____________(Found on fee receipt for original filing) NOTE: If registrant is applying to sell securities of which it is the issuer, the registrant must file on NY Form M-11, Issuer Statement (IPS M-11). Broker/Dealer Firm Name_______________________________ Telephone No._________________________________________ Branch offices in New York State: Name and Address Principal Office Address _________________________________ Street Address _________________________________________ City State Zip Code _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 1. Is registrant now licensed, or otherwise qualified to transact securities or commodities business in any other state? Yes ___No ___ If "Yes", list state(s) ____________________________________________________________________________ 2. For the following questions, indicate whether any of the following apply to the registrant, any officer, director or principal or partner. If any answer is "Yes", attach a detailed explanation. Have any of the persons specified above... A. ever been suspended or expelled from membership in any securities or commodities exchange, association of securities commodities dealers or investment or commodities trading advisors or council? B. Yes ____No ___ ever had a license or registration as a dealer, broker, investment advisor, salesperson futures commission merchant, associated Yes ____No ___ person commodity pool operator, or commodity trading advisor denied, suspended or revoked? C. ever been enjoined or restrained by any court or government agency from........... 1. 2. 3. 4. the issuance, sale or offer for sale of securities or commodities? ................ rendering securities or commodities advice or counsel?............................. handling or managing trading accounts?............................................... continuing any practices in connection with securities or commodities?......... Yes ____No _____ Yes ____No ___ Yes ____No ___ Yes ____No ___ Yes ____No ___ Yes ____No ___ D. ever been convicted of any crime? ........................................................... E. ever used or been known by any other name? ............................................. Please indicate where the fee receipt should be sent: [ ] Attorney [ ] Broker/Dealer Firm __________________________________________________ Attorney or Broker/Dealer Firm Name __________________________________________________ Street Address __________________________________________________ City State Zip IPS M-1 (09/10) Filing Fee for Broker-Dealer Statement ...... $1200.00 Make check payable to the NYS Department of Law. Payment by Attorney's check, company check, certified check, bank check or money order only. Personal checks not accepted. Send remittance to: Investor Protection and Securities Bureau NYS Department of Law 120 Broadway, 23rd Floor New York, New York 10271 American LegalNet, Inc. www.FormsWorkFlow.com 3. 4. 5. Does registrant furnish investment advice for compensation? ................................ Has registrant sold securities to the public within the last three years? ..................... Does registrant meet the net capital requirements as described in NY Gen. Bus. Law Sec.352-k? (If at any time you do not meet the net capital requirements, you must notify NYS Department of Law) Yes ____No ___ Yes ____No ___ Yes ____No ___ 6. Are fingerprints on file with any of the following?: [ ] SEC [ ] NASD [ ] New York State......................................................... [ ] N.Y. or other major exchange, indicate which: ________________________________________________________________________________________________________ Yes ____No ___ 7. 8. Registrant has been a securities broker for _________years. Has actual control of registrant changed during past five years? Yes _____No ___ If "Yes", attach a detailed explanation of the sources of all registrant's capital (including amounts from each source). 9. Give nature and location of each business in which registrant has engaged during the preceding five years. From (Month/Year) To (Month/Year) Business Location and Nature __________________________________________________________________________________________ __________________________________________________________________________________________ 10. For each officer, director, principal, or partner, please provide the information requested. If additional space is necessary, please attach additional pages. 10a. Name: ________________________________________________ Phone: ________________________________________ Date of Birth: ___________ Birth Place:_____________ Social Security #: _______________________________ Title: _________________________________________________ Residence: ____________________________________________ Prior home addresses for past five years: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ List complete employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment. Include all corporations or other entities where individual holds or held a substantial equity or controlling interest.) From Mo./ Yr. To Mo./ Yr. Employer or Business Affiliation Name Address Position Held and Type of Business American LegalNet, Inc. www.FormsWorkFlow.com IPS M-1 (09/10) Page 2 10b. Name: ________________________________________________ Phone: ________________________________________ Date of Birth:_____________ Birth Place: ____________ Social Security #: ________________________________ Title: _________________________________________________ Residence: ____________________________________________ Prior home addresses for past five years: ________________________________________________________________________________________________________ _________________________________________________________________
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