Uniform registration application. Uniform 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 for sale of franchises _________ Registration renewal statement or annual report Amendment number _________ to application filed under section _________ dated _________
_________ Posteffective _________ Preeffective
1. Name of Franchisor _________. Name under which the Franchisor is doing or intends to do business _________. 2. Franchisor's principal business address _________. Name and address of Franchisor's agent in the State of _________(Name of State) authorized to receive process _________. 3. Name, address and telephone number of subfranchisors, if any, for this state _________. 4. Name, address and telephone number of person to whom communications regarding this application should be directed _________.
Supplemental Information 1. List the following: A. The states in which this proposed registration is effective. B. The states in which this proposed registration is or will be shortly on file. C. The states, if any, which have refused, by order or otherwise, to register these franchises. D. The states, if any, which have revoked or suspended the right to offer these franchises. E. The states, if any, in which the proposed registration of these franchises has been withdrawn. 2. With respect to all franchises sought to be registered set forth in budget form, the total projected financing required by franchisor to fulfill the franchisor's obligations to provide real estate, improvements, equipment, inventory, training and all other items included in the offering. Show separately the sources of all of the required funds including any proposed loans or contributions to capital. Salesmen Disclosure Form 1. As required by this State's statute, list the persons who will engage in the offer or sale of franchises in this state and for each person list the following information: A Name; B Business address and telephone number; C Home address and telephone number; D Present employer; E Present title; F Social security number; G Birthdate; and H Employment or occupation during the past five years. For each such employment state the name of the employer, position held and beginning and ending dates for each such employment. 2. State whether any person identified in Item 1 above: A. Has any administrative, civil or criminal action pending against him alleging a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? Yes _________ No _________ B. Has during the 10-year period immediately preceding the date of the offering circular:
(1). been convicted of a felony or pleaded nolo contendere to a felony charge or been held liable in a civil action by final judgment if such felony or civil action involved a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable violations of law? Yes _________ No _________ (2). entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, securities, antitrust, monopoly, trade practice, or trade regulation law? Yes _________ No _________ (3). been subject to any order of any national securities association or national securities exchange (as defined in the Securities and Exchange Act of 1934) suspending or expelling such person from membership in such association or exchange. Yes _________ No _________ C. With respect to each question above answered "Yes" state: (1) the name of each person or entity involved; (2) the court, agency, association or exchange involved; (3) a summary of the allegations; (4) if applicable, the date of the conviction, judgment, decree, order or assurance; and (5) the penalty imposed, damages assessed and nature thereof, terms and conditions of the judgment, decree, order or assurance. Uniform Consent to Service of Process Know all men by these presents: That the undersigned, _________(a corporation organized under the laws of the State of _________) (a partnership) (an individual) (_________(other)), for the purpose of complying with the laws of the State of _________ relating to the registration, exemption from registration or sale of franchises, hereby irrevocably appoints the _________(regulatory authority), and the successors in such office, its attorney in the State of _________ upon whom may be served any notice, process or pleading in any action or proceeding against it arising out of or in connection with the sale of franchises, or out of violation of the aforesaid laws of said State; and the undersigned does hereby consent that any such action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue within said State by service of process upon said officer with the same effect as if the undersigned was organized or created under the laws of said State and had lawfully been served with process in said State. It is requested that a copy of any notice, process or pleading served hereunder be mailed to: _________(Name and Address)
Dated: _________, 19__. By _________ Title _________ (Seal) By _________
Title _________ Corporate Acknowledgment State of _________ ss County of _________
On this _________ day of _________, 19__, before me _________(Name of Notary) the undersigned officer, personally appeared _________ and _________, known personally to me to be the _________ President and _________ Secretary, respectively, of the above named corporation, and that they, as such officers, being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by themselves as such officers. In witness whereof I have hereunto set my hand and official seal. Notary Public _________ (Notarial Seal) My Commission expires: _________
Individual or Partnership Acknowledgment State of _________ ss County of _________
On this _________ day of _________, 19__, before me, _________, the undersigned officer, personally appeared _________ to me personally known and known to me to be the same person(s) whose name(s) is (are) signed to the foregoing instrument, and acknowledged the execution thereof for the uses and purposes therein set forth. In witness whereof I have hereunto set my hand and official seal.
Notary Public _________ (Notarial Seal) My Commission expires: _________
I certify under penalty of law that I have read this application and the exhibits attached hereto and incorporated herein by reference, and know the contents thereof and that the statements therein are true and correct. Executed at _________, _________, 19__. (Signature(s) of Franchisor and/or Subfranchisor) By _________ Title _________ (Seal) 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 _________
Instructions The following instructions must be adhered to with respect to all applications for registration, registration renewal and amendment. 1. Completion of Application: An application for registration of the offer or sale of franchises shall include the following, all of which shall be verified by means of the prescribed signature page: A. Facing page. B. Supplemental information page(s). C. Salesmen disclosure form for all states except Washington. D. A copy of the proposed offering circular.
The following shall be attached to the application: A. A second copy of the proposed offering circular. B. A cross reference sheet showing the location in the franchise agreement of the information required to be included in the application and in the offering circular. If any item calling for information is inapplicable or the answer thereto is in the negative and is omitted, a statement to that effect shall be made in the cross reference sheet. C. Two copies of any advertising to be used in connection with the offer or sale in this state of franchises. D. A consent to service of process. 2. Definitions: A. "Predecessor," for the purposes of the disclosure required by Item 1 in the body of the offering circular, is defined as follows: A "predecessor" of a franchisor is (i) a person the major portion of whose assets have been acquired directly or indirectly by the franchisor, or (ii) a person from whom the franchisor acquired directly or indirectly the major portion of its assets. B. "Franchise broker," for the purposes of the disclosure required by the cover page and Item 2 in the body of the offering circular, is defined as follows: A "franchise broker" is any person engaged in the business of representing a franchisor or subfranchisor in offering for sale or selling a franchise, except anyone whose identity and business experience is otherwise required to be disclosed at Item 2 in the body of the offering circular. 3. Disclosure: Each disclosure item should be either positively or negatively commented upon by use of a statement which fully incorporates the information required by the item. 4. Subfranchisors: When the person filing the application for registration is a subfranchisor, the application shall also include the same information concerning the subfranchisor as is required from the franchisor; the franchisor, as well as the subfranchisor, shall execute a signature page. 5. Signing of Application: The application shall be signed by an officer or general partner of the applicant; however, it may be signed by another person holding a power of attorney for such purposes from the applicant. If signed on behalf of the applicant pursuant to such power of attorney, the application shall include as an additional exhibit a copy of said power of attorney or a copy of the corporate resolution authorizing the attorney to act. 6. Manually Signed Consent of Accountant: All applications shall be accompanied by manually signed consent of the independent public accountant for the use of their audited financial statements as such statements appear in the offering circular. 7. Application To Amend the Registration: An amendment to an application filed either before or after the effective date of registration shall contain only the information being amended identified by item number and shall be verified by means of the prescribed signature page. Each amendment shall be accompanied by a facing page in the form prescribed on which the applicant shall indicate that the filing
is an amendment and the number of the amendment, if more than one. 8. Note: This Uniform Franchise Registration Application is an alternative means of complying with the state franchise investment laws. Because the Uniform Application form was designed to satisfy the varied requirements of a number of states, it may call for more information than any one state demands. Applicants should be aware that they may, if they wish, elect to file in each state the application form prescribed in that state, rather than the Uniform Application form.