Director'S Affiliations Form - New York State Department Of Financial Services

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New York State Department of Financial Services
DIRECTOR’S AFFILIATIONS
Institution ___________________________________________
Date __________________
20 ____
Name of Director _____________________________________
Originally Elected ________
20 ____
Business ___________________________________________
Term Expires ___________
20 ____
Please check which should be used as your mailing address.
( ) Business Address ____________________________________________________________________
( ) Home Address _______________________________________________________________________
Signature ________________________________________________
BUSINESS AFFILIATIONS INCLUDING CORPORATIONS OF WHICH YOU ARE AN OFFICER OR DIRECTOR OR WHICH YOU
CONTROL THROUGH STOCK OWNERSHIP AND PARTNERSHIPS OF WHICH YOU ARE A MEMBER
PERCENT
BUSINESS OF FIRM
OFFICIAL POSITION
NAME OF FIRM OR CORPORATION
REMARKS
OF
OR
IN
INTEREST
CORPORATION
FIRM OR CORPORATION
OWNED
%
%
%
%
%
%
%

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