Notification of Changes for Business Entity
General Information
Business Entity Name:	SUTHERLAND GLOBAL SERVICES
Incorporation / Formation Date:
FEIN:	FEIN 16-1287080
Ohio License Number:	32628
NPN:	8372079
DBA / Trade Name:
State of Domicile:	NY
County:	PITTSFORD
Business Address
Address 1:	1160 PITTSFORD VICTOR ROAD
Address 2:
City:	PITTSFORD
State:	NY
Zip:	14534
Phone:	8667748570
Fax:	7574311940
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1313 EXECUTIVE BLVD
Address 2:
City:	CHESAPEAKE
State:	VA
Zip:	23323
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
BAEZ, MARILYN	PRODUCER	102585694	YES		11/09/2016
BAKER, VALERIE	PRODUCER	229066205	YES		11/09/2016
BAZEMORE, REBECCA	PRODUCER	080584967	YES		11/09/2016
CLARK, EBONY R	PRODUCER	230515344	YES		11/09/2016
CURRY, GARY	PRODUCER	236046561	YES		11/09/2016
DAVISON, CHARLENE	PRODUCER	249438960	YES		11/09/2016
DIXON, SHAWNITA	PRODUCER	226085913	YES		11/09/2016
DUKE, KRISTI	PRODUCER	226667200	YES		11/09/2016
ELEY, TRINA YOLANDA	PRODUCER	218027595	YES		11/09/2016
ERWIN, TASHA	PRODUCER	129744824	YES		11/09/2016
EVANS, SHEILA	PRODUCER	230885218	YES		11/09/2016
FOY, ROBERT	PRODUCER	246025744	YES		11/09/2016
GAMEZ, ROBERT	PRODUCER	102760939	YES		11/09/2016
GORDON, RENINA	PRODUCER	231416200	YES		11/09/2016
KELLY, JAMES	PRODUCER	225376876	YES		11/09/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

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:	CAROLYN CLARK
Title:	LICENSING ADMIN
Phone Number:	866-774-8570
Email Address:	CAROLYNL.CLARK@SUTHERLANDGLOBAL.COM