Form Njbos-5 - New Jersey Addendum To Registration Statement printable pdf download

Form NJBOS-5 7/02

NEW JERSEY ADDENDUM TO REGISTRATION STATEMENT

PART A: TO BE COMPLETED BY ISSUER

1. Has the issuer, any partner, officer, or director of the issuer, any person (as that term is defined in N.J.S.A. 49:3-

49(i)) occupying a similar status or performing similar functions, or any person directly or indirectly controlling

or controlled by the issuer:

(a) been convicted of:

(i) any crime of embezzlement under state, federal, or foreign law?

Yes ___ No ___

(ii) any crime involving any theft, forgery, or fraudulent practices in regard to any state, federal, or foreign

securities law, investment advisory law, banking law, insurance law, commodities trading law, or

antifraud law?

Yes ___ No ___

(b) been permanently or temporarily enjoined by any court of competent jurisdiction from engaging in or

continuing any conduct or practice involving any aspect of the securities, commodities, banking, insurance,

or investment advisory business?

Yes ___ No ___

registration or registration as a broker-dealer, agent, investment adviser, or investment adviser

representative?

Yes ___ No ___

(d) been the subject of any order entered by any federal or state securities, commodities, banking, insurance, or

investment advisory administrator or self-regulatory organization denying or revoking any securities,

commodities, banking, insurance, or investment advisory license or registration, under federal or state

securities, commodities, banking, insurance, or investment advisory law, including, but not limited to,

registration as a broker-dealer, agent, investment adviser, or investment adviser representative, or the

substantial equivalent of those terms as defined in this act, or been the subject of an order of the Securities

and Exchange Commission, a self-regulatory organization, the Commodity Futures Trading Commission,

an insurance commissioner, or a federal or state banking regulator, suspending or expelling him from a

national securities or commodities exchange or national securities or commodities association registered

under the “Securities Exchange Act of 1934" (15 U.S.C. 78a et seq.) or the “Commodity Exchange Act” (7

U.S.C. 1a et seq.) or from engaging in the banking or insurance business, or been the subject of a United

States Postal Service fraud order?

Yes ___ No ___

(e) ever been found by any court in a civil or criminal action by any state or federal agency to have engaged in

any act involving fraud, or dishonest or unethical practices in the securities, commodities, banking,

insurance, or investment advisory business?

Yes ___ No ___

2. (a) Is the person filing the registration statement or the issuer, any partner, officer, or director of the issuer, any

person (as that term is defined in N.J.S.A. 49:3-49(i)) occupying a similar status or performing similar

functions, or any person directly or indirectly controlling or controlled by the issuer, or other person

involved directly or indirectly in the offering, insolvent, either in the sense that liabilities exceed assets or

in the sense that obligations cannot be met as they mature?

Yes ___ No ___

Form Njbos-5 - New Jersey Addendum To Registration Statement