Sponsors And Selling Agents Broker Dealer Statement - New York Department Of Law Page 2
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44. Name of cooperative, condominium, homeowners association, senior residence or timeshare which gave rise to this filing.
____________________________________________________________________________________________________
Address of same ______________________________________________________________________________________
___________________________________________________________________________________________________
5. The offering or selling will take place in:
[ ] New York State only.
[ ] New York and other states: specify _______________________________________________________
6. The offering will be made by:
[ ] officers, directors, members, managers, and employees of registrant.
[ ] selling agent. If so, give name(s) and address(es): ___________________________________________
_______________________________________________________________________________________
7. Has registrant, any officer, director, member, principal, partner, or manager ever:
A. been suspended or expelled from membership in any securities exchange,
association of securities dealers or investment advisers or counsel? ....................
Yes [ ]
No [ ]
B. had a license or registration as a dealer, broker, investment adviser or
salesperson denied, suspended or revoked? ..........................................................
Yes [ ]
No [ ]
C. been enjoined or restrained by any court or agency including the NYS Department of Law from:
1. the issuance, sale or offer for sale of securities? .............................................
Yes [ ]
No [ ]
2. rendering securities advice or counsel? ...........................................................
Yes [ ]
No [ ]
3. handling or managing trading accounts? .........................................................
Yes [ ]
No [ ]
4. continuing any practices in connection with securities? .................................
Yes [ ]
No [ ]
D. Entered into an Assurance of Discontinuance with the NYS Department of Law
Yes [ ]
No [ ]
whereby that person agreed not to issue, sell or offer for sale securities, or act as a
broker or dealer, directly or indirectly of
E. been convicted of any crime? ...............................................................................
Yes [ ]
No [ ]
F. used or been known by any other name? If “Yes,” give other name(s)................
Yes [ ]
No [ ]
G. been the subject of any professional disciplinary proceeding? .............................
Yes [ ]
No [ ]
H. Filed for bankruptcy [ ] been adjudged a bankrupt or made a general assignment for the benefit of
creditors or been an officer, director, member, principal, manager of any entity which
was reorganized in bankruptcy, adjudged a bankrupt or made a general
assignment for the benefit of creditors? ................................................................
Yes [ ]
No [ ]
I. had an offering or selling of securities within the last three years or been an officer,
director, principal, member, partner or manager of any entity which had sold or
Yes [ ]
No [ ]
offered securities within the last three years? ......................................................
If any answer to any of the above (Question 7) is “Yes,” attach statement of full particulars, giving date, nature
of offense, title and location of agency or court involved, circumstances and final disposition.
8. List names and residence addresses of all securities salespersons (if none, so indicate).
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
REF M-10 (06/2016) Page 2 of 4
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