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Supplement (Forms M-1, M-1A, M-11, M-10) M-3 - New York
| Supplement (Forms M-1, M-1A, M-11, M-10) 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 NY FORM M-3 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 NYS File Number/CRD Number_______________ (NYS File Number found on fee receipt for original filing) SUPPLEMENT TO N.Y. FORMS BD, M-10, M-11 (Section 359-e General Business Law) ALL CHANGES OCCURRING WITHIN 30 DAYS CAN BE FILED ON ONE M-3 FORM (WITH ATTACHMENTS IF NEEDED) FOR $30 FEE. Type of Supplement G BD G M-10 G M-11 NASD member firms can submit amendments directly through CRD. Broker/Dealer Firm Name_____________________________________________________________________________________ Principal Office Address _____________________________________________________________________________________ _____________________________________________________________________________________ City State Zip Code Telephone No.______________________________________________________________________________________________ 1. CHANGE OF SECURITIES SALESPERSON. A. NEW SALESPERSON(S) EMPLOYED. Note: include a Salesperson Statement (M-2 or U4) or Supplemental Salesperson Stmt.(M-4) for each new employee. Name Address Date of Hire _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ B. SALESPERSON(S) TERMINATED. Name SSN# Date and Reason for Termination _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 2. CHANGE IN: G FIRM NAME or G ADDRESS or G BRANCH OFFICE ADDRESS. CHANGE DATE _________ From: _______________________________________________________________________________________________ To: _________________________________________________________________________________________________ 3. For each occasion when registrant or any of its officers, directors, principals or salespersons is convicted of any criminal offense involving securities or commodities investment advisory services or of any felony, or is restrained by any court or governmental agency from engaging in any practice involving securities investment advisory services or commodities. G Attach a copy of the judgment, order, etc. TERMINATION OR WITHDRAWAL OF DEALERSHIP AS OF _______________________________________ (DATE). Reason: _____________________________________________________________________________________________ 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-3 (11/06) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 4. Fee for Supplement to BD, M-10 or M-11 Statement ...... $ 30.00 Make check payable to the NYS Department of Law. Payment by Attorney's check, company check, certified check, bank check or money order. Personal checks not accepted. Send remittance to: Investment Protection Bureau NYS Department of Law 120 Broadway, 23rd Floor New York, New York 10271 5. CHANGES IN OFFICERS, DIRECTORS OR OTHER PRINCIPALS. The information set forth below should be provided for each new officer, director, principal or partner. In the case of a corporate partner, information must be provided for all officers of corporate general partner. If additional space is needed, attach additional pages. Terminating officers should complete Name, Date of Change, Social Security Number and Nature of Change items only. Social security numbers and residential information are strictly confidential. Name: Address: Prior home addresses for the past 5 years: Telephone: Date of Birth: Date of Change: 6. Has any officer, director, principal or partner of the Issuer: Social Security #: Place of Birth: Nature of Change: A. ever been suspended or expelled from membership in any securities or commodities exchange, association of securities or commodities dealers or investment advisers? Yes [ ] No [ ] B. ever had a license or registration as a dealer, broker, investment adviser or salesperson, futures commission merchant, associated person, commodity pool operator, or commodity trading advisor denied, suspended or revoked? Yes [ C. ever been enjoined or restrained by any court or agency from: 1. the issuance, sale or offer for sale of securities or commodities? 2. rendering securities or commodities advice? 3. handling or managing trading accounts? 4. continuing any practices in connection with securities or commodities? D. ever been convicted of any crime (other than minor traffic)? E. ever used or been known by any other name? F. ever been the subject of any professional disciplinary hearing or proceeding or settled customer complaints or arbitrations in excess of $10,000? G. ever been adjudged a bankrupt or made a general assignment for the benefit of creditors; or been an officer, director or principal of any entity which was reorganized in bankruptcy, adjudged a bankrupt or made a general assignment for the benefit of creditors? H. ever had an offering of securities within the last three years or been an officer, director, principal or partner of any entity which had an offering of securities within the last three years? 7. Are there any outstanding judgments (not including judgments of domestic relations) against the issuer or any officer, director, principal or partner thereof ? ] No [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ Yes [ Yes [ ] ] ] No [ ] No [ ] No [ ] No [ ] No [ No [ No [ ] ] ] Yes [ Yes [ ] ] No [ No [ ] ] Yes [ ] No [ ] If the answer to any of the above (questions 6 and 7) is "Yes", attach statement of full particulars. I hereby affirm and represent that all statements contained herein are true, I understand that any false statements shall constitute a violation of Article 23-A of the General Business Law. Date: _________________________ Signature: ______________________________________________________________________ Individual proprietor, partner, or principal officer of corporation, trust or association. IPS M-3 (11/06) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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