NY Form CM-3 ** File No. _____________ (1/87) STATE OF NEW YORK Office of the Attorney General BUREAU OF INVESTOR PROTECTION AND SECURITIES SUPPLEMENTAL COMMODITY STATEMENT SUPPLEMENT TO N.Y. FORMS CBD, CADV All changes occurring within 30 days can be filed on a single CM-3 (with attachments if necessary) and one fee. Firm Principal ________________________ ____________________________ Name Office Street Address Telephone ____________________ _____________________________ City State Zip A COMMODITY BROKER-DEALER OR COMMODITY INVESTMENT ADVISOR SHALL, NOT LATER THAN 30 DAYS AFTER OCCURRENCE, COMPLETE THIS STATEMENT TO REPORT: 1. CHANGE OF COMMODITY SALESPERSONS: A. New commodity salespersons employed. A Commodity Salesperson Statement (CM-2) or Supplemental Commodity Salesperson Statement (CM4) for each new employee must accompany this form. Date Name Address __________________________________________________________________ ___________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ B. Commodity Salespersons terminated: Reason for Date Termination Name Address __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ __________________________________________________________________ ____________________ 2002 © American LegalNet, Inc. 2. CHANGE IN FIRM NAME, ADDRESS, OR N.Y.S. BRANCH OFFICE. Date ____________ From: __________________________________________________________ To: ________________________________________________________________________ _______ 3. Each occasion when registrant or any of its officers, directors, principals, partners, managers, supervisors, salespersons, 10% or more equity holders or any entity in which said individual is a principal is suspended or expelled from membership in any securities or commodities exchange, 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 proceeding; 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 documentation about the occurrence of any of the above. 4. TERMINATION OR WITHDRAWAL OF REGISTRATION as of __________ date. Reason: _______________________________________________________ 5. CHANGES IN OR TERMINATION OF OFFICERS, DIRECTORS, PRINCIPALS, PARTNERS, SUPERVISORS, MANAGERS OR ANY 10% OR MORE EQUITY HOLDER. Use attachments if necessary. Name: _______________________________ Date of Change: _____________________ Nature of Change: ___________________ Reason for Change: __________________ 6. FOR EACH NEW OFFICER, DIRECTOR, PRINCIPAL, PARTNER, SUPERVISOR, MANAGER OR ANY 10% OR MORE EQUITY HOLDER ATTACH A COPY OF FORM CI-1. 2002 © American LegalNet, Inc. 7. Has new officer, director, principal, partner, supervisor, manager. 10% or more equity holder of the registrant or any entity in which such individual was a principal ever: A. been suspended or expelled from membership in any securities or commodities exchange, association of securities or commodities dealers or investment or commodities trading advisors or counsel?.......................... Yes [ ] No [ ] B. had 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? .................................................. Yes [ ] No [ ] C. been enjoined or restrained by an 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. Is any action or proceeding seeking the relief enumerated in A - C presently pending?...................Yes [ ] No [ ] E. been convicted of any crime?.......................... Yes [ ] No [ ] F. used or been known by any other name?................. Yes [ ] No [ ] G. been the subject of any professional disciplinary proceeding?.............................. Yes [ ] No [ ] H. been adjudged a bankrupt or made a general assignment for benefit of creditors; been the subject of a receivership or bankruptcy proceeding; been an officer, director, principal, partner, manager, supervisor or any 10% or more equity holder of any entity which was reorganized in bankruptcy, adjudged a bankrupt or made a general assignment for benefit of creditors?............ Yes [ ] No [ ] I. ever had a judgment entered against them or it which is presently unsatisfied? (Not including judgments involving domestic relations.)............................................ Yes [ ] No [ ] J. been 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?.........................Yes [ ] No [ ] K. if any answer to any of the above is "YES", attach statement of full particulars. 2002 © American LegalNet, Inc. A $10.00 fee must accompany this statement. Personal checks not accepted. Attorney's check, bank check, certified check, money order only payable to the N.Y.S. Office of the Attorney General. Attach additional sheets where space provided is inadequate. You may submit a photocopy of this form. It will be returned with your fee receipt for your records. Send remittance to: Bureau of Investor Protection and Securities, 23rd Floor, N.Y. Office of the Attorney General, 120 Broadway, New York, NY 10271. DATED: _______________ Signature: ____________________________________________ STATE OF ) : S.: COUNTY OF ) ________________________________, being duly sworn, deposes and says that I am the ___________________ (Title) of Registrant 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/Chief Executive Officer of Registrant) Sworn to before me this day of , 20 (Notary signature and legible official stamp) V.N. 2002 © American LegalNet, Inc.