Broker Dealer Statement {M-1}

NY FORM M-1 NEW YORK STATE DEPARTMENT OF LAW INVESTOR PROTECTION BUREAU Floor New York, NY 101-800-771-7755 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 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 Principal Office Address Telephone No. Street Address City State Zip Code Branch offices in New York State: Name and Address 1.Is registrant now licensed, or otherwise qualified to transact securities or commodities business in any other state? Yes No If 223Yes224, list state(s) 2.For the following questions, indicate whether any of the following apply to the registrant, any officer, director or principal orpartner. If any answer is 223Yes224, 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 securitiescommodities dealers or investment or commodities trading advisors or council? Yes No B. ever had a license or registration as a dealer, broker, investment advisor, salesperson futures commission merchant, associated person commodity pool operator, or commodity trading advisor denied, suspended or revoked? Yes No C. ever been enjoined or restrained by any court or government agency from........... 1.the issuance, sale or offer for sale of securities or commodities? ................Yes No 2.rendering securities or commodities advice or counsel?.............................Yes No 3.handling or managing trading accounts?...............................................Yes No 4.continuing any practices in connection with securities or commodities?.........Yes No D. ever been convicted of any crime? ........................................................... Yes No E. ever used or been known by any other name? ............................................. Yes No Please indicate where the fee receipt should be sent: [ ] Attorney [ ] Broker/Dealer Firm Attorney or Broker/Dealer Firm Name Street Address City State Zip Filing Fee for Broker-Dealer Statement ...... $1200.00 Make check payable to the NYS Department of Law. Payment by Attorney222s check, company check, certified check, bank check or money order only. Personal checks not accepted. Send remittance to: Investor ProtectionBureau NYS Department of Law , 2 Floor New York, New York 10 IP M-1 () American LegalNet, Inc. www.FormsWorkFlow.com 3.Does registrant furnish investment advice for compensation? ................................Yes No 4.Has registrant sold securities to the public within the last three years? .....................Yes No 5.Does registrant meet the net capital requirements as described in NY Gen. Bus. Law Sec.352-k?Yes No (If at any time you do not meet the net capital requirements, you must notify NYS Department of Law)6.Are fingerprints on file with any of the following?:[ ] SEC [ ] NASD [ ] New York State......................................................... Yes No [ ] N.Y. or other major exchange, indicate which: 7.Registrant has been a securities broker for years.8.Has actual control of registrant changed during past five years? Yes No If 223Yes224, attach a detailed explanation of the sources of all registrant222s 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: Title: Date of Birth: Birth Place: Residence: Social Security #: 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 IP M-() Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 10b. Name: Phone: Title: Date of Birth: Birth Place: Residence: Social Security #: 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 10c. Name: Phone: Title: Date of Birth: Birth Place:Residence: Social Security #: 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 IP M-1 ( Page 3 American LegalNet, Inc. www.FormsWorkFlow.com 10d. Name: Phone: Title: Date of Birth: Birth Place: Residence: Social Security #: 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 11.List name, residence and nature of employment for all account executives, securities salespersons, customer222s employees, andregistered representatives employed to sell in NY State. These persons must file or have on file a NY Form M-2 or M-4.NOTE: NASD member firms who have registered their salespeople through the CRD system do not need to answer this question.Name Address Nature of Employment Each of the undersigned, constituting all officers, directors, partners, and controlling principals of the registrant, does hereby state and represent that all statements contained herein are true and correct and each understands that any false statement shall constitute a violation of Article 23-A of the General Business Law. Power of Attorney is not acceptable. Please type or print. Attach additional paper if necessary. Signature Name and Title Date To complete this filing a State Notice form must be filed with the NYS Secretary of State. Also, in the case of non-resident brokers, a Consent to Service of Process form must be filed with the Secretary of State. All changes or amendments to this form must be submitted on NY Form M-3 with a fee of $30.00. IP M-1 Page 4 American LegalNet, Inc. www.FormsWorkFlow.com