NY Form CI-1 COMMODITY INFORMATION SHEET (1/87) TO: ATTORNEY GENERAL OF THE STATE OF NEW YORK BUREAU OF INVESTOR PRO TECTION AND SECURITIES 1. _______________________________________________________________________ Last Name First Name Middle Name 2. ______________________________________________________________________ Residence Address State City Zip Code 3. (a)________________________________ (b) ______________________________ Residence Phone Business Phone 4. (a) ______________________________ (b) ______________________________ Place of Birth Date of Birth 5. __________________________________ Social Security Number 6. Name of Registrant: __________________________________________________ >>>> 27. Have you or has any business entity under your control or in which you were a principal shareholder (10% or more) or in which you held a substantial equity or controlling interest (10% or more) or of which you were an officer, director, general partner, trustee or principal, manager, supervisor: a) ever used or been known by any other name? Yes ( ) No ( ) b) ever been convicted of any crime (other than minor traffic violations) Yes ( ) No ( ) c) ever been the subject of any injunction, cease and desist order, assurance of discontinuance, suspension or restraining order, revocation of a license to practice a trade, occupation or profession, denial of an application to obtain or renew same, any stipulation or consent to desist from any act or practice, any disciplinary action by any court or administrative agency, or is any action or proceeding seeking such relief presently pending? Yes ( ) No ( ) d) ever made an assignment for the benefit of creditors, been the subject of a receivership or bankruptcy proceeding, reorganized in bankruptcy, or been adjudged a bankrupt? Yes ( ) No ( ) e) ever had a judgment entered against you or it which is presently unsatisfied? (Not including judgments involving domestic relations.) Yes ( ) No ( ) f) Are you or is any business entity under your control or in which you were a principal shareholder (10% or more) or in which you held a substantial equity or controlling interest (10% or more) or of which you were an officer, director, general partner, trustee, or principal, a party in any litigation or administrative proceeding in which it is alleged that you or it committed fraud or otherwise violated any provision of the Martin Act or any other securities or commodities laws? Yes ( ) No ( ) If the answer to any of the above is "YES" state full particulars, including dates, nature of proceeding, title and location of public authoity, circumr stances and final disposition. If there is insufficient space below, complete response in an attached, sworn statement. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ >>>> 3 8. List all professional, business or occupational licenses or registrations which you now hold, have held, or have applied for: ______________________________________________________________________ ______________________________________________________________________ 9. The following is my complete employmnt record including periods of self-eemployment and unemployment for the past five years: ____________________________________________________________________ From To Name and Address Type of Mo. Yr. Mo. Yr. of Employer Business Position Held ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ >>>> 410. The following is a complete record of mysiness affiliations for th bu e past five years, including all entities not listed in 12 above, under my control or in which I was a principal shareholder (10% or more) or in which I held a substantial equity or controlling interest (10% or more) or of which I was an officer, director, general partner, trustee or principal. ____________________________________________________________________ From To Name & Address Type of Affiliation/ Mo. Yr. Mo. Yr. of Entity Business Position ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Dated: _______________________ Signature: ______________________________ ___ STATE OF ) : SS.: COUNTY OF ) _____________________________________, being duly sworn, deposes and says that I am the person described in and who signed the above registration form. I have read the questions and answers and information supplied, and they are true, accurate and complete.