A Franchise Registration Forms

Section 200 Section 200.APPENDIX A   Franchise Registration Forms Section 200.ILLUSTRATION C   Sales Agent Disclosure Form 1.          List the persons who will offer or sell franchises in this State.  For each person state: 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 during the past 5 years.  For each such employment state the name of the employer, position held and beginning and ending dates. 2.         State whether any person identified in 1. above: A.        Has any administrative, civil or criminal action pending alleging a violation of franchise or securities 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 before the Offering Circular date: (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 the felony or civil action involved a violation of franchise or securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or comparable violation of law? YES NO (2)       entered into or been named in any consent judgment, decree, order or assurance under 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, 15 U.S.C. 78a) suspending or expelling the person from membership in the 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.