** File no. NY Form CM-4(/) STATE OF NEW YORK Office of the Attorney General INVESTOR PROTECTION SUPPLEMENTAL COMMODITY SALESPERSON STATEMENT The Supplemental Commodity Broker-Dealer Statement (CM-3) must accompany this report of new employment Last Name First Name Middle Name Soc. Sec. # Residence, Street Address City State Zip A Commodity Salesperson shall, not later than 30 days after occurrence , complete this statement to report: 1.CHANGE OR TERMINATION OF EMPLOYMENT Date Reason for Termination Termination Name (Former Employer) Address New Employer Date Commenced Address 2.CHANGE IN NAME OR RESIDENCE From:To: Date: 3.Each occasion when a salesperson or any entity in which said salesperson is a principal issuspended or expelled from membership in an y securities or commodities exchan g e, association of securities or commodities dealers or investment or commodities trading advisors or counsel; has a license or registration as a securities or commodity dealer, broker, investment advisor, salesperson, futures commission merchant, associated person, commodity pool operator or commodity trading advisor denied, suspended, revoked, cancelled or refused; is enjoined or restrained by any court or government agency from: the issuance, sale or offer for sale of securities or commodities, rendering securities or commodities advice or counsel, handling or managing trading accounts, continuing any practices in connection with securities or commodities; is convicted of any crime; uses or is known by any other name; is the subject or any professional disciplinary proceeding; is adjudged a bankrupt or makes a general assignment for benefit of creditors; is the subject of a receivership or bankruptcy proceedings; is an officer, director, principal, partner, manager, supervisor or any 10% or more equity holder of any entity which is reorganized in bankruptcy, adjudged a bankrupt or makes a general assignment for benefit of creditors; has a judgment entered against them or it which is presently unsatisfied (not including judgments involving domestic relations); is a party in any litigation or administrative proceeding in which it is alleged that they or it committed fraud or otherwise violated any provision of the Martin Act or any other securities or commodities laws. Supply full details and Page 1of 2Investors - Form CM4 American LegalNet, Inc. www.FormsWorkFlow.com documentation about the occurrence of an y of the above.NOTE: No fee required to cancel registration. However, re-employment as a salesperson of commodities after cancellation will require a new registration and payment of $25 filing fee. 4.[ ] CANCEL MY COMMODITY SALESPERSON REGISTRATION. A $10.00, fee must accompany this statement. Personal checks not accepted. Attorney's check, certified check, money order only payable to the N.Y.S Office of the Attorney General. Remit to:Investor Protection, 2 Floor, NYS Office of the Attorney General, , New York, NY 10. DATED: Signature: STATE OF ) : SS.: COUNTY OF ) , bein g dul y sworn, deposes and says that I am the Commodity Salesperson described above and I signed the above form. I have read the questions and answers and information supplied, and they are true, accurate and complete. (Signature of Affiant/Salesperson) Sworn to before me this da y of , 19 (Notary signature and legible official stamp) (spe) **Found on the fee receipt for original filing Page 2of 2Investors - Form CM4 American LegalNet, Inc. www.FormsWorkFlow.com