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Sponsors And Selling Agents Broker Dealer Statement M-10 - New York
| Sponsors And Selling Agents 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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N.Y. Form M-10 (Rev. 1/97) STATE OF NEW YORK DEPARTMENT OF LAW BUREAU OF REAL ESTATE FINANCING SPONSORS AND SELLING AGENTS BROKER DEALER STATEMENT Out-of-state or foreign firms must attach a certified copy of a designation for the service of process from the Secretary of State.Attach additional sheets if space provided is inadequate. For assistance in completing form, call Real Estate Financing Bureau: (212) 416-8106. A check or money order for the filing fee must accompany this statement. Filing fee, which is good for four years, is $200 plus $10each per partner, proprietor, principal, officer or director, payable to N.Y. S. Department of Law, 120 Broadway - 23rd floor, NewYork, N.Y. 10271. Name of Registrant Telephone No.: Address Street City State ZipOther offices, if any 1. Registrant is a [ ] corporation [ ] general partnership [ ] limited partnership [ ] sole proprietor [ ] limited liability company [ ] other: specify Organized under the laws of 2. Registrant is a [ ] sponsor. [ ] selling agent. If a licensed real estate broker, give state license number and expiration date _____________________________________________________________________________ [ ] holder of unsold shares of a cooperative corporation. [ ] purchaser for investment or resale of unsold shares of a cooperative corporation. [ ] seller of interests in a homeowners association. [ ] other: specify ______________________________________________________________________ 3. If registrant is a new or substitute sponsor of a cooperative, condominium, homeowners association, timeshare or a holder of unsold shares of a cooperative corporation, has this been disclosed in an offering plan or amendment? Yes [ ] No [ ] 4. Address, and name, if any, of cooperative, condominium, homeowners association or timeshare which gave rise to this filing. 5. Registrant intends to offer or sell [ ] stock of cooperative housing corporation [ ] condominium units (including stock of or membership in condominium associations or corporations) [ ] homeowners association interests in real estate. [ ] timeshare interest <<<<<<<<<********>>>>>>>>>>>>> 26. The offering or selling will take place in [ ] New York State only [ ] New York and other states: specify 7. The offering will be made by [ ] officers, directors and employees of registrant [ ] selling agent. If so, give name(s) and address(es): __________________________________ 8. Has registrant, any officer, director, principal or partner ever A. been suspended or expelled from membership in any securities exchange, association of securities dealers or investment advisors or counsel? ....................Yes [ ] No [ ] B. had a license or registration as a dealer, broker, investment advisor or salesperson denied, suspended or revoked? .......................................................... Yes [ ] No [ ] C. been enjoined or restrained by any court or agency from: 1. the issuance, sale or offer for sale of securities? .............................................Yes [ ] No [ ] 2. rendering securities advice or counsel? ..........................................................Yes [ ] No [ ] 3. handling or managing trading accounts? ........................................................Yes [ ] No [ ] 4. continuing any practices in connection with securities? ..................................Yes [ ] No [ ] D. been convicted of any crime? ..............................................................................Yes [ ] No [ ] E. used or been known by any other name? If "yes, give other name(s)..................Yes [ ] No [ ] F. been the subject of any professional disciplinary proceeding? ..............................Yes [ ] No [ ] G. been adjudged a bankrupt or made a general assignment for benefit of creditors or been an officer, director or principal or any entity which was reorganized in bankruptcy, adjudged a bankrupt or made a general assignment for benefit of creditors? ........................................................Yes [ ] No [ ] H. had an offering or selling of securities within the last three years or been an officer, director, principal or partner of any entity which had sold or offered securities within the last years ................................................................Yes [ ] No [ ] If any answer to "A, "B, "C, "D, "E, "F, "G, "H, is "Yes, attach statement of full particulars, giving date, nature of offense, title and location of agency or court involved, circumstances and final disposition. <<<<<<<<<********>>>>>>>>>>>>> 3 9. List names and residence addresses of all securities salespersons (if none, so indicate)._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________10. Provide the following information for each proprietor, officer, director, principal or partner. A. Name: _________________________________________ Title: ________________________________ Home Address: ________________________________ Phone: ______________________________ Place of Birth: _________________________________ Date of Birth: _________________________ Social Security No.: ______________________________ Other home addresses for past ten years: ____ ______________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________Complete employment and business affiliation record for the past five years. Include periods of self-employment and unemployment. Include all corporations or other entities where person holds or held a substantial equity or controlling interest. FROM TO EMPLOYER OR BUSINESS AFFILIATION POSITION HELD Mo. Yr. Mo. Yr. Name Address_______________________________________________________________________________________________ B. Name:_________________________________________Title:__________________________________ Home Address: __________________________________Phone: Place of Birth Date of Birth: Social Security No.: _________________________________ Other home addresses for past ten years:___ _______________________________________________________________________________________________<<<<<<<<<********>>>>>>>>>>>>> 4 ______
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