New York > Secretary Of State > Blue Sky > Investor Protection And Securities
Salesperson Statement M-2 - New York
| Salesperson 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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N.Y. Form M-2 ** File No.______ (Rev. 4/89) Not to be used by salesperson of NASD member firms STATE OF NEW YORK, Office of the Attorney General BUREAU OF INVESTOR PROTECTION AND SECURITIES SALESPERSON STATEMENT The Supplemental Broker-Dealer Statement (NY Form M-3) must accompany this report of new employment) 1.__________________________________________________________ Last Name First Name Middle Name 2.__________________________________________________________ Attach 2x2 Residence: City State photo taken 3.___________________________4.______________________________ within the Social Security Month Day Year preceding 5.__________________________________________________________ six months. Place of Birth Date of Birth 6._______________7._______________8.____________9.Ft.___In.____ Color of Hair Color of Eyes Weight Height 10. Have you used or been known by any other name? .......................................... Yes [ ] No [ ] If "YES", give other names 11. Have you ever been convicted of any criminal offense involving securities or commodities, or of any felony whatsoever? .......................................... Yes [ ] No [ ] 12. Have you ever been enjoined or restrained by any court or government agency from a. the sale or offer for sale of securities or commodities? .......................................... Yes [ ] No [ ] b. continuing any practices in connection therewith? .......................................... Yes [ ] No [ ] c. rendering securities or commodities advice? .......................................... Yes [ ] No [ ] d. handling or managing trading accounts? .......................................... Yes [ ] No [ ] 13. Has any license or registration to act as an investment advisor or sell securities or commodities as a dealer, broker, salesperson, futures commission merchant, associated person, commodity pool operator, or commodity trading advisor, ever been revoked, cancelled or refused? .......................................... Yes [ ] No [ ] 14. Have you ever been suspended or expelled from any stock or commodities exchanges, or association of securities dealers, brokers, salespersons, investment advisors, or counsel? .......................................... Yes [ ] No [ ] <<<<<<<<<********>>>>>>>>>>>>> 215. If the answer to 11, 12, 13, 14, is "YES", attach full particulars giving dates, nature of offense, title and location of public authorty involved, circumstances and final disposition .......................................... Yes [ ] No [ ] 16. Insert name and address of employer (Broker-Dealer) ______________________________________________________________________ Name Address _____________________________________________________________________ City State 17. Do you serve as an investment advisor? .......................................... Yes [ ] No [ ] If so, state name of service, whether full or part time, scope of duties and compensation._________________________________________________________ ______________________________________________________________________ 18. Following is my complete employment record for the past five years: (Indicate periods of self-employment & unemployment). ______________________________________________________________________ From To Employer Position Held Mo. Yr. Mo. Yr. Name Address Present ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 319. Following is my complete educational history: Attended From To Did You Name of School and Location Mo. Yr. Mo. Yr. Graduate Elementary School________________________________________________________ High School _____________________________________________________________ College University ________________________________________________________ Or Technical School _______________________________________________________ Other Schools or __________________________________________________________ Special Courses __________________________________________________________ I hereby grant permission to the Attorney General to examine without notice any filings made with the New York or American Stock Exchanges or National Association of Securities Dealers, Inc. I hereby state and represent that I am the person who executed the foregoing Salesman Statement, that all the answers and facts continued therein are true and that I fully understand that any false statement shall constitute a violation of Article 23-A of the General Business Law. Dated: __________________ _______________________________ Signature A $100 fee must accompany this statement. Personal checks not accepted. Attorneys check, bank check money order only, payable to the NYS Department of Law. Attach additional sheets where space provided is inadequate. Submit a photocopy of this form. We will return it to you with your fee receipt as an acknowledgment of registration. Send remittance to: Bureau of Investor Protection and Securities N.Y.S. Office of the Attorney General 120 Broadway New York, N.Y. 10271 (ea) **Found on the fee receipt you received for original filing.
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