Ny Form M-2 - Salesperson Statement Page 2

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15. Name and address of the employer (Broker-Dealer): _______________________________________________________
________________________________________________________________________________________________
Street
City
State
Zip
License No.:
Expiration Date:
_______________________________________________________________
________________
16. Do you serve as an investment adviser?.............................................................
Yes [
]
No [
]
If so, state the name of the service, whether it is full or part time, the duties and the compensation.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
17. Complete employment record for the past five years, including periods of self-employment and unemployment
beginning with the most recent.
Employer
Dates (Mo. & Yr.)
Position Held
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
18. Complete educational history:
Name of School and Location
Dates (Mo. & Yr.)
Did You Graduate?
l
Yes [
]
No [
]
High Schoo
College, University
Yes [
]
No [
]
or, Technical
Yes [
]
No [
]
Other
I hereby grant permission to the Attorney General to examine without notice any filings made with the New York
Stock Exchange, American Stock Exchange or NASD.
I hereby represent that I am the person who executed the foregoing Salesperson Statement, that all the answers and
facts contained therein are true and that I fully understand that any false statement shall constitute a violation of Article 23-A
of the General Business Law.
Furthermore, I hereby represent that I am registering with the Attorney General solely for the purpose of selling
condominiums, shares of cooperative apartment corporations or commercial cooperative corporations, interests in
homeowners associations or interests in timeshare projects; and that I will not act as a securities salesperson with respect to
any securities other than those described above, unless and until I have undertaken and successfully completed a uniform
securities agent state law examination as administered by or on behalf of the North American Securities Administrators
Association, Inc. (NASAA) by any national securities association or national securities exchange and have provided proof of
successful completion of such examination requirement to the Attorney General.
Date:___________________________ Signature____________________________________________________________
IPS M-2 (11/06) Page 2 of 2

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