Form Ri-1 - Registrant Information - Department Of Law Page 2
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211. The following is my complete employment and business record including periods of self-employment and unemployment for the
past five years:
From
To
Name and Address
Type of
Position Held
of Employer
Business
Mo. Yr.
Mo. Yr.
12. The following is a complete record of my business affiliations for the past five years, including all entities not listed in 11 above,
under my control or in which I was a principal shareholder (10% or more) or in which I held a substantial equity or controlling
interest (10% or more) or of which I was an officer, director, general partner, trustee or principal.
From
To
Name and Address
Type of
Position Held
of Entity
Business
Mo. Yr.
Mo. Yr.
Date: _______________ Signature: _______________________________
STATE OF
)
: SS.:
COUNTY OF
)
_____________________________________, being duly sworn, deposes and says that I am the person described in and who
signed the above registrant information form. I have read the questions and answers and information supplied, and they are true, accurate
and complete.
_______________________________________________
(Signature of Affiant)
Sworn to before me this
_______ day of ______________, 20______.
(Notary signature and legible official stamp)
_______________________
_____________________
President
or
General Partner
IPS RI-1 (11/06) Page 2 of 2
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