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Registrant Information Form RI-1 - New York
| Registrant Information Form 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 INVESTMENT 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 NY FORM RI-1 REGISTRANT INFORMATION FORM 1. _____________________________________________________________________________________________________________ Last Name First Name Middle Name 2. _____________________________________________________________________________________________________________ Business Address Street City State Zip Code 3. ________________________________ Place of Birth 4(a). ___________________________ Date of Birth 4(b). ___________________________________ Business Phone 5. Name of Issuer: ________________________________________________________________________________________________ 6. Have you ever used or been known by any other name? If "Yes", please specify______________________________________________________________ 7. Have you or has any business entity under your control or in which you were a principal shareholder (10% or more) or in which you held a substantial equity or controlling interest (10% or more) or of which you were an officer, director, general partner, trustee or principal: (a) ever been convicted of any crime (other than minor traffic violations) or is any such charge presently pending: (b) ever been the subject of any injunction, cease and desist order, assurance of discontinuance, suspension or restraining order, revocation of a license to practice a trade, occupation or profession, denial of an application to obtain or renew same, any stipulation or consent to desist from any act or practice, any disciplinary action by any court or administrative agency, or is any action or proceeding seeking such relief presently pending? (c) ever made an assignment for the benefit of creditors, been the subject of a receivership or bankruptcy proceeding, reorganized in bankruptcy, or been adjudged a bankrupt? (d) ever had a judgment entered against you or have a judgement which is presently unsatisfied? 8. Are you or is any business entity under your control or in which you were a principal shareholder (10% or more) or in which you held a substantial equity or controlling interest (10% or more) or of which you were an officer, director, general partner, trustee or principal, a party in any litigation or administrative proceeding in which it is alleged that you or it committed fraud or otherwise violated any provision of the Martin Act or any other securities law? 9. If the answer to 7(a) through (d), or 8 is "Yes" state full particulars, including dates, nature of proceeding, title and location of public authority, circumstances and final disposition. If there is insufficient space below, complete response in an attached, sworn statement. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 10. List all professional, business or occupational licenses or registrations which you now hold, have held, or have applied for: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ IPS RI-1 (11/06) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Yes [ ] No [ ] Yes [ ] No [ ] Yes [ Yes [ Yes [ ] ] ] No [ No [ No [ ] ] ] Yes [ ] No [ ] 11. The following is my complete employment and business record including periods of self-employment and unemployment for the past five years: From Mo. Yr. Mo. To Yr. Name and Address of Employer Type of Business Position Held 12. The following is a complete record of my business affiliations for the past five years, including all entities not listed in 11 above, under my control or in which I was a principal shareholder (10% or more) or in which I held a substantial equity or controlling interest (10% or more) or of which I was an officer, director, general partner, trustee or principal. From Mo. Yr. Mo. To Yr. Name and Address of Entity Type of Business Position Held Date: _______________ Signature: _______________________________ STATE OF COUNTY OF ) : SS.: ) _____________________________________, being duly sworn, deposes and says that I am the person described in and who signed the above registrant information form. I have read the questions and answers and information supplied, and they are true, accurate and complete. _______________________________________________ (Signature of Affiant) Sworn to before me this _______ day of ______________, 20______. (Notary signature and legible official stamp) _______________________ _____________________ General Partner President or IPS RI-1 (11/06) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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