Form Cm-4 - Supplemental Commodity Salesperson Statement

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NY Form CM-4
** File no.______
(1/87)
STATE OF NEW YORK Office of the Attorney General
BUREAU OF INVESTOR PROTECTION AND SECURITIES
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 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 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

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