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Supplement (Forms M-1, M-1A, M-11, M-10) Form. This is a New York form and can be use in Blue Sky Secretary Of State.
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Tags: Supplement (Forms M-1, M-1A, M-11, M-10), M-3, New York Secretary Of State, Blue Sky
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
G
BD
G
M-10
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.
4.
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
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
IPS M-3 (11/06) Page 1 of 2
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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:
Social Security #:
Date of Birth:
Place of Birth:
Date of Change:
Nature of Change:
6.
Has any officer, director, principal or partner of the Issuer:
A. ever been suspended or expelled from membership in any securities or commodities exchange,
association of securities or commodities dealers or investment advisers?
Yes [ ]
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 [
]
No [
]
No [
]
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?
No [ ]
No [ ]
No [ ]
No [ ]
D. ever been convicted of any crime (other than minor traffic)?
Yes [
]
No [
]
E. ever used or been known by any other name?
Yes [
]
No [
]
F. ever been the subject of any professional disciplinary hearing or proceeding or settled
customer complaints or arbitrations in excess of $10,000?
Yes [
]
No [
]
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?
Yes [
]
No [
]
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.
Yes [ ]
Yes [ ]
Yes [ ]
Yes [ ]
Yes [
]
No [
]
Are there any outstanding judgments (not including judgments of domestic relations)
against the issuer or any officer, director, principal or partner thereof ?
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
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