Form M-3 -Supplemental Broker Dealer Statement - State Of New York Department Of Law - 2014

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N.Y. Form M-3
File No. __________________
(Rev. 1/14)
(Found on fee receipt for original filing.)
STATE OF NEW YORK DEPARTMENT OF LAW
REAL ESTATE FINANCE BUREAU
SUPPLEMENTAL BROKER DEALER STATEMENT
Firm Name________________________________
Principal Office_______________________________________________
Street Address
Phone No._________________________________
____________________________________________________________
City
State
Zip
A securities broker or dealer shall, not later than 30 days after occurrence, complete this statement. All changes occurring within
30 days can be filed on one M-3 (with attachments if necessary). Attach additional sheets if space provided is inadequate. You
may submit a photocopy of the form to be return with your fee receipt as an acknowledgment of registration.
Change of securities salesperson. (Not for FINRA member firms who must file a U-4 with the Central
1.
Registration Depository.)
A. NEW SALESPERSONS EMPLOYED. A Salesperson Statement (Form M-2) or Supplemental Salesperson
Statement (Form M-4) for each new employee must accompany this form.
Date
Name
Address
_________________________________________________________________________________________________
_________________________________________________________________________________________________
B. SALESPERSONS TERMINATED.
Date
Name
Address
Reason for Termination
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2.
CHANGE IN FIRM NAME OR ADDRESS OR BRANCH OFFICE. Date_____________________________________
From: ____________________________________________________________________________________________
To: ______________________________________________________________________________________________
3.
TERMINATION OR WITHDRAWAL OF DEALERSHIP AS OF ________________ DATE.
Reason:___________________________________________________________________________________________
4.
Change in officers, directors or other principals. The information set forth below must be provided for each officer,
director, principal or partner. For a corporate partner, information must be provided for all officers of the corporate
general partner. If the change is termination of an officer, only the first three lines need to be completed.
Name:____________________________________________________________________________________________
Date of Change:________________________________ Nature of Change:_____________________________________
Home Address:_____________________________________________________________________________________
Phone No.:____________________________________ Social Security No.:____________________________________
For foreign applicants without a social security number, provide one of the following:
Individual Taxpayer Identification Number: __________________________________
Passport Number: _______________________ (Annex photocopy hereto)
Date of Birth:__________________________________ Place of Birth:________________________________________

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