Public Member Notice of Interest to DFS to Serve on NYAIP Governing Committee or Peer Review Panel:

This form will serve as your application to the Department of Financial Services (DFS) to serve as their Public Member recommendees on the NYAIP Governing Committee or DFS appointees to the Peer Review Panel for 2023.

This application will be provided to DFS, and they will contact you directly for further information.

Question Title

* 1. I am submitting my Notice of Interest to serve :

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

NY DFS License Number (PC/BR)

Email Address *

Phone Number *

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* 2. I am interested in serving in the following capacity:

Governing Committee: Wherever needed: Either a Principal or Alternate Member

Governing Committee: Principal Member Only

Governing Committee: Alternate Member Only

Peer Review Panel :Wherever needed: Either a Principal or Alternate Member

Peer Review Panel Principal Member Only

Peer Review Panel Alternate Member Only

Either Committee in any capacity

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* 3. Please list all Trade Association affiliations:

PIA

BIG I

CIBGNY

NY-YIP

None

Other (please specify)

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* 4. DFS is requesting you provide your qualifications and employment history for the past 5 years. You may either:

a) after completing this document, send your resume directly to DFS at the email addresses provided below, or

b) insert the details below, (they will be included in this document being provided to DFS on your behalf),

a) I prefer to send my resume to Rejani.Nair@dfs.ny.gov and Holford.Marshall@dfs.ny.gov

b) My Qualifications and 5 Year Work History are provided below:

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* 5. DFS is requesting you provide information regarding any complaints that may have been filed against you with DFS in the past 5 years, and how they were resolved.

Please send this information directly to DFS at Rejani.Nair@dfs.ny.gov and Holford.Marshall@dfs.ny.gov

I acknowledge this requirement

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* 1. I am submitting my Notice of Interest to serve :

Question Title

* 2. I am interested in serving in the following capacity:

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* 3. Please list all Trade Association affiliations:

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* 5. DFS is requesting you provide information regarding any complaints that may have been filed against you with DFS in the past 5 years, and how they were resolved. Please send this information directly to DFS at Rejani.Nair@dfs.ny.gov and Holford.Marshall@dfs.ny.gov

Question Title

* 6. Please provide any additional comments for DFS consideration:

* 5. DFS is requesting you provide information regarding any complaints that may have been filed against you with DFS in the past 5 years, and how they were resolved.

Please send this information directly to DFS at Rejani.Nair@dfs.ny.gov and Holford.Marshall@dfs.ny.gov