STATE OF NEW YORK DEPARTMENT OF LAW
INVESTMENT PROTECTION BUREAU
NY FORM M-2
(REAL ESTATE FINANCE SECTION)
120 Broadway, 23
rd
Floor
New York, NY 10271-0332
1-800-771-7755 TTD (for hearing impaired) 1-800-788-9898
*NYS File Number _________________
SALESPERSON STATEMENT
If used to report new employment, a Supplemental Broker-Dealer Statement, N.Y. Form M-3, must accompany this Form M-
2, unless employed by a licensed broker. In such case, give broker’s license number and expiration date in space provided
below.
Attach 2 x 2 photo taken within
1. ________________________________________________________________________
Last Name
First Name
Middle Name
the preceding six months
2. ________________________________________________________________________
Residence Street
City
State
Zip
3. ______________________________ 4. ______________________________
Social Security No.
Date of Birth
5. __________________________________________________________________
Place of Birth
6. _______________ 7. ______________ 8. ______________ 9. ______________
l
Hair Color
Eye Color
Weight
Height
10. Have you used or been known by any other name?.................................................... Yes [
]
No [
]
If “Yes”, give other name(s)......................................................................................
11. Have you ever been convicted of any criminal offense involving securities or
commodities, or of any felony whatsoever?..............................................................
Yes [
]
No [
]
12. Have you ever been enjoined or restrained by any court or governmental
agency from:
a. the sale or offer for sale of securities or commodities?..............................
Yes [
]
No [
]
b. continuing any practices in connection therewith?......................................
Yes [
]
No [
]
c. rendering securities or commodities advice?..............................................
Yes [
]
No [
]
d. handling or managing trading accounts?.....................................................
Yes [
]
No [
]
13. Has any license or registration to act as an investment adviser or to sell
securities or commodities as a dealer, broker, salesperson, futures commission
merchant, associated person, commodity pool operator, or commodity trading
advisor, ever been revoked, canceled or refused?..............................................
Yes [
]
No [
]
14. Have you ever been suspended or expelled from any stock or commodities
exchanges, or association of securities’ dealers, brokers, salespersons,
investment advisers, or counsel?........................................................................
Yes [
]
No [
]
If the answer to 11, 12, 13, or 14 is “Yes”, attach a statement of the full particulars giving the date, the nature of the offense,
the title and the location of the agency or court involved, the circumstances and the final disposition.
Fee for Salesperson Statement......................... $150.00
Make check payable to the NYS Department of Law.
Send remittance to:
Investment Protection Bureau
Payment by Attorney's check, company check, certified
NYS Department of Law
check, bank check or money order. Personal checks not
Real Estate Finance Section
rd
accepted.
120 Broadway, 23
Floor
New York, New York 10271
*NYS File Number found on fee receipt for original filing.
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