NY FORM M-4 NEW YORK STATE DEPARTMENT OF LAW INVESTPROTECTION BUREAU, 2 FloorNew York, NY 101-800-771-7755 TDD (for hearing impaired) 1-800-788-9898 www.ag.ny.gov *NYS File Number/CRD NumberSUPPLEMENTAL SALESPERSON STATEMENTThe Supplemental Broker-Dealer Statement must accompany this report of new employment.This form should not be used by salespersons of NASD member firms.Salesperson Last Name First Name Middle Name Street Address City State ZipSocial Security # Social security numbers and residential information are strictly confidential.A Securities Salesperson shall, not later then 30 days after occurrence, complete this statement to report:1.CHANGE OR TERMINATION OF EMPLOYMENT. If dual registration, so indicate.Date Terminated Reason Terminated Name (Former Employer) Address New Employer Date Commenced Address Real Estate License No. Expiration Date 2.CHANGE IN NAME OR ADDRESS.To: From: Date: 3.DISCLOSURE ITEMS. Specify nature of offense, dates, circumstances and final disposition for each occasion when salesperson isconvicted of any criminal offense involving securities or commodities or of any felony whatsoever, or is restricted by any court orgovernmental agency from engaging in any practice involving securities or commodities.4.[ ] CANCEL MY SALESPERSON REGISTRATION.NOTE:No fee required to cancel registration. However, re-employment as a salesperson of securities after cancellationwill require a new registration and payment of $150 filing fee.I hereby state and represent that I am the person who executed the foregoing Supplemental Salesperson Statement, that all theanswers and facts contained therein are true and that I fully understand that any false statement shall constitute a violation ofArticle 23-A of the General Business Law.Date: Signature: Fee for Supplemental Salesperson Statement............... $30.00Payment by Attorney's check, company check, certified check,bank check or money order. Personal checks not accepted.Make check payable to the NYS Department of Law. Send remittance to: InvestProtection Bureau NYS Department of Law, 2 FloorNew York, New York 10 *NYS File Number found on fee receipt for original filing IP M-4 () American LegalNet, Inc. www.FormsWorkFlow.com