Sponsors And Selling Agents Broker Dealer Statement - New York Department Of Law Page 3
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49. Provide the following information for each proprietor, officer, director, member, principal, partner or manager. Attach
continuation sheets if more space is needed. All fields must be completed, or form will be deemed incomplete.
A.
Name: ________________________________________ Title: __________________________________________
Home Address: _________________________________ Phone: ________________________________________
Place of Birth: _________________________________ Date of Birth: ___________________________________
Social Security No.: _____________________________
For foreign applicants without a social security number, provide one of the following:
Individual Taxpayer Identification Number: _______________________________
Passport Number: _______________________ (Annex photocopy hereto)
Other home addresses for past ten years:
_______________________________________________________________________________________________
Complete employment and business affiliation record for the past five years. Include periods of self-employment and unemployment.
Include all corporations, partnerships, limited liability companies or other entities where person holds or held a substantial equity or
controlling interest.
From
To
Employer or Business Affiliation
Position Held
Mo. Yr.
Mo. Yr.
Name
Address
B.
Name: ________________________________________ Title: __________________________________________
Home Address: _________________________________ Phone: ________________________________________
Place of Birth: _________________________________ Date of Birth: ___________________________________
Social Security No.: _____________________________
For foreign applicants without a social security number, provide one of the following:
Individual Taxpayer Identification Number: _____________________________
Passport Number: _______________________ (Annex photocopy hereto)
Other home addresses for past ten years:
_______________________________________________________________________________________________
Complete employment and business affiliation record for the past five years. Include periods of self-employment and unemployment.
Include all corporations, partnerships, limited liability companies or other entities where person holds or held a substantial equity or
controlling interest.
From
To
Employer or Business Affiliation
Position Held
Mo. Yr.
Mo. Yr.
Name
Address
REF M-10 (06/2016) Page 3 of 4
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