Ny Form Cbd - Bureau Of Investor Protection And Securities Commodity Broker-Dealer Statement 1987 Page 4

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CM-3 with a $10 fee. Registration will expire one year from filing.
To renew your registration you must refile this form within 30 days
of expiration.
DATED:_________________ Signature:________________________________
STATE OF
)
: SS.:
COUNTY
)
__________________________, being duly sworn, deposes and says that I am
the _________________ (Title) of Registrant and I signed the above form. I have
read the questions and answers and information supplied, and they are true,
accurate and complete
______________________________
_
(Signature of Affiant/Chief
Executive Officer of Registrant)
Sworn to before me this
day of
, 19
(Notary signature and legible official stamp)
(spe)

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