NYF-1
1-81
STATE OF NEW YORK
Office of the Attorney General
BUREAU OF INVESTOR PROTECTION AND SECURITIES
FRANCHISE REGISTRATION APPLICATION
_____________________________________
File No.
______________________________________
(insert file number of previous
filings of Applicant, if any)
FEE:__________________________________
(To be enclosed by
Applicant at time
application is initially
filed)
Date of Application:__________________
APPLICATION FOR (Check only one):
______ REGISTRATION OF AN OFFER OR SALE OF FRANCHISES
______REGISTRATION RENEWAL STATEMENT OR ANNUAL REPORT
AMENDMENT NUMBER ___________ TO APPLICATION
1. Name of Franchisor _________________________________________
Name under which the Franchisor is doing or intends
to do business _________________________________________________
2. Franchisor's principal business address _______________________
______________________________________________________________
3. Name and address of Franchisor's agent in the State of
New York authorized to receive process.
_______________________________________________________________
_______________________________________________________________
4. Name, address and telephone number of subfranchisors,
if any, for the State of New York _____________________________
______________________________________________________________
______________________________________________________________
_______________________________________________________________
5. Name, address and telephone number of person to whom
communications regarding this application should be directed.
_______________________________________________________________
_______________________________________________________________
SUPPLEMENTAL INFORMATION
Set forth, on separate sheets, annexed as riders hereto, a statement as to each
franchise salesman employed by the franchisor, containing the information as to his
identity and litigation called for by section 200.4 (c)(2) and (3) of these regulations.
NYF-2
1-81
STATE OF NEW YORK
Office of the Attorney General
BUREAU OF INVESTOR PROTECTION AND SECURITIES
STATE OF )
: SS.:
COUNTY OF )
____________________________________, being duly sworn,
deposes and says:
1. That (he) (she) has read this application and the exhibits thereto and knows the
contents thereof and that the same are true to (his) (her) own knowledge.
2. That all the information required by Article 33 of the General Business Law of
the State of New York and the regulations issued thereunder, has been disclosed.
3. That to (his) (her) knowledge, the application and the exhibits thereto fully and
fairly disclose the material aspects of the offering and contain no material
misrepresentations or omissions.
4. That the franchisor agrees to amend the exhibits or any of them when any event
requiring amendment occurs.
____________________________________
Signature of Franchisor
and/or Sub-Franchisor
(SEAL)
By___________________________________
Title_______________________________
Sworn to before me this
day of 19
_______________________________
NOTARY PUBLIC
STATE OF __________________)
: SS.:
COUNTY OF ________________)
Personally appeared before me this ___________ day of ____________________,
19__, the above-named _______________________
________________________________ (and) _____________________________ to me
known to be the person(s) who executed the foregoing application (as
______________________ and ______________________
___________________ respectively, of the above-named applicant) and (each), being
first duly sworn, stated upon oath that said application, and all exhibits submitted
herewith, are true and correct.
______________________________________
(Notary's Seal) ______________________________________
(Notary)