Notification of Changes for Business Entity
General Information
Business Entity Name:	COMMERCE AND INDUSTRY BROKERAGE, INC.
Incorporation / Formation Date:
FEIN:	205761962
Ohio License Number:	41205
NPN:
DBA / Trade Name:
State of Domicile:	NY
County:	NEW YORK
Business Address
Address 1:	125 WEST 55TH STREET
Address 2:
City:	NEW YORK
State:	NY
Zip:	10019
Phone:	212-231-1234
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	125 WEST 55TH STREET
Address 2:
City:	NEW YORK
State:	NY
Zip:	10019
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
GABRIEL GALANSKI	RDA	17406005	YES		01/15/2016

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	JOHANNA MILLER
Title:	LICENSING COORDINATOR
Phone Number:	9196535456
Email Address:	JOHANNA.MILLER@REGED.COM