Salesperson Statement {M-2}

NY FORM M-2 Attach 2 x 2 photo taken withinthe preceding six months STATE OF NEW YORK DEPARTMENT OF LAWINVEST PROTECTION BUREAU(REAL ESTATE FINANCE SECTION), 2 FloorNew York, NY 101-800-771-7755 TTD (for hearing impaired) 1-800-788-9898 www.ag.ny.gov*NYS File Number SALESPERSON STATEMENTIf used to report new employment, a Supplemental Broker-Dealer Statement, N.Y. Form M-3, must accompany this Form M-2, unless employed by a licensed broker. In such case, give broker222s license number and expiration date in space providedbelow.1.Last Name First Name Middle Name2.Residence Street City State Zip3. 4. Social Security No. Date of Birth5.Place of Birth6. 7. 8. 9. Hair Color Eye Color WeightHeight10.Have you used or been known by any other name?....................................................Yes [ ]No [ ] If 223Yes224, give other name(s)......................................................................................11.Have you ever been convicted of any criminal offense involving securities or commodities, or of any felony whatsoever?..............................................................Yes [ ]No [ ]12.Have you ever been enjoined or restrained by any court or governmentalagency from:a.the sale or offer for sale of securities or commodities?..............................Yes [ ]No [ ]b.continuing any practices in connection therewith?......................................Yes [ ]No [ ]c.rendering securities or commodities advice?..............................................Yes [ ]No [ ]d.handling or managing trading accounts?.....................................................Yes [ ]No [ ]13.Has any license or registration to act as an investment adviser or to sellsecurities or commodities as a dealer, broker, salesperson, futures commissionmerchant, associated person, commodity pool operator, or commodity trading advisor, ever been revoked, canceled or refused?..............................................Yes [ ]No [ ]14.Have you ever been suspended or expelled from any stock or commoditiesexchanges, or association of securities222 dealers, brokers, salespersons, investment advisers, or counsel?........................................................................Yes [ ]No [ ]If the answer to 11, 12, 13, or 14 is 223Yes224, attach a statement of the full particulars giving the date, the nature of the offense,the title and the location of the agency or court involved, the circumstances and the final disposition.Fee for Salesperson Statement......................... $150.00 Payment by Attorney's check, company check, certifiedcheck, bank check or money order. Personal checks notaccepted.Make check payable to the NYS Department of Law. Send remittance to: Invest Protection Bureau NYS Department of LawReal Estate Finance Section, 2 FloorNew York, New York 10 *NYS File Number found on fee receipt for original filing. IP M-2 () Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 15.Name and address of the employer (Broker-Dealer): Street City State ZipLicense No.: Expiration Date: 16.Do you serve as an investment adviser?.............................................................Yes [ ]No [ ] If so, state the name of the service, whether it is full or part time, the duties and the compensation. 17.Complete employment record for the past five years, including periods of self-employment and unemploymentbeginning with the most recent. Employer Dates (Mo. & Yr.) Position Held 18.Complete educational history:Name of School and Location Dates (Mo. & Yr.) Did You Graduate? High School Yes [ ] No [ ]College, Universityor, Technical Yes [ ] No [ ]Other Yes [ ] No [ ] I hereby grant permission to the Attorney General to examine without notice any filings made with the New YorkStock Exchange, American Stock Exchange or NASD.I hereby represent that I am the person who executed the foregoing Salesperson Statement, that all the answers andfacts contained therein are true and that I fully understand that any false statement shall constitute a violation of Article 23-Aof the General Business Law.Furthermore, I hereby represent that I am registering with the Attorney General solely for the purpose of sellingcondominiums, shares of cooperative apartment corporations or commercial cooperative corporations, interests inhomeowners associations or interests in timeshare projects; and that I will not act as a securities salesperson with respect toany securities other than those described above, unless and until I have undertaken and successfully completed a uniformsecurities agent state law examination as administered by or on behalf of the North American Securities AdministratorsAssociation, Inc. (NASAA) by any national securities association or national securities exchange and have provided proof ofsuccessful completion of such examination requirement to the Attorney General. Date:SignatureIP M-2 () Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com