Franchise Registration Application

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF BUSINESS REGULATION SECURITIES DIVISION 1511 PONTIAC AVENUE, JOHN O. PASTORE COMPLEX BLDG 69-1 CRANSTON, RI 02920 RHODE ISLAND FRANCHISE REGISTRATION APPLICATION ENCLOSE CORRECT FEE WHEN APPLICATION IS INITIALLY FILED APPLICATION FOR (Check only one): REGISTRATION OF AN OFFER AND SALE OF FRANCHISES REGISTRATION RENEWAL STATEMENT OR ANNUAL REPORT AMENDMENT NUMBER POST-EFFECTIVE TO APPLICATION $600.00 $300.00 $120.00 FILED UNDER SECTION FISCAL YEAR END: EIN# 1. Name of Franchisor. subfranchisor.) (If applicant is a subfranchisor, the name of the 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 Rhode Island authorized to receive process. 3. Name, address and telephone number of subfranchisors, if any for this state. to whom 4. Name, address, email address and telephone number of person communications regarding this application should be directed. 5. Mandatory Addendum to License Application - Tax Payer Status Affidavit / Identity Verification. (ATTACHED) FRANCHISE APPLICATION PAGE 1 OF 10 American LegalNet, Inc. www.FormsWorkFlow.com SUPPLEMENTAL INFORMATION 1. Disclose: A. B. C. D. E. The states in which this proposed registration application is effective. The states in which this proposed registration application is or will be shortly on file. The states that have refused to register this franchise offering. The states that have revoked or suspended the right to offer franchises. The states in which this proposed registration of these franchises has been withdrawn within the last five years, and the reasons for revocation or suspension. 2. Source of Funds for Establishing New Franchises Disclose franchisor's total costs for performing its pre-opening obligations to provide goods or services in connection with establishing each franchise, including real estate, improvements, equipment, inventory, training and other items stated in the offering. State separately the sources of all required funds. FRANCHISE APPLICATION PAGE 2 OF 10 American LegalNet, Inc. www.FormsWorkFlow.com CONSENT TO SERVICE OF PROCESS ,(a corporation organized under the laws of the state of ) (a partnership) (an individual) , irrevocably appoints the Director of the Rhode Island Department of Business Regulation and the successors in office, its attorney, in the state of for service of notice, process or pleading in an action or proceeding against it arising out of or in connection with the sale of franchises, or a violation of the franchise law of Rhode Island, and consents that an action or proceeding against it may be commenced in a court of competent jurisdiction and proper venue within Rhode Island by service of process upon this officer with the same effect as if the undersigned was organized or created under the law of Rhode Island and had lawfully been served with process in Rhode Island. It is requested that a copy of any notice, process or pleading served this consent be mailed to: Dated: , 20 . By (SEAL) Title By Title FRANCHISE APPLICATION PAGE 3 OF 10 American LegalNet, Inc. www.FormsWorkFlow.com SALESMAN DISCLOSURE FORM 1. As required by Rhode Island 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. G. H. Social Security number: Birth date: Employment or occupation during the past 5 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 the person identified in 1 above: A. Has any administrative, civil or criminal action pending against him alleging a violation of any franchise law, business opportunity law, securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? YES NO Has been convicted of a felony or pleaded nolo contendere to a felony charge? FRANCHISE APPLICATION PAGE 4 OF 10 American LegalNet, Inc. www.FormsWorkFlow.com Salesman Disclosure continued--C. Has during the 10 year period immediately preceding the date of the offering circular: (1) been convicted or a misdemeanor or pleaded nolo contendere to a misdemeanor charge or been held liable in a civil action by final judgment if such misdemeanor or civic action involved a violation of any franchise law, business opportunity law, securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation or property or any comparable violation of law? YES (2) NO entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, business opportunity, securities, anti-trust, monopoly, trade practice, or trade regulation? 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 D. With respect to each question above answered "YES" state: (1) (2) (3) (4) (5) the name of each person or entity involved; the court, agency, association or exchange involved; a summary of the allegations; if applicable, the date of the conviction, judgement, decree, order or assurance; and the penalty imposed, damages assessed and nature thereof, and terms and conditions of the judgment, decree, order or assurance. FRANCHISE APPLICATION PAGE 5 OF 10 American LegalNet, Inc. www.FormsWorkFlow.com CORPORATE ACKNOWLEDGMENT STATE OF COUNTY OF On me appeared personally to me to be the respectively, of the above-named corporation, this day ) ) ss. ) of , 20 , before , the undersigned officer, personally and and and that they, as , known , such officers, being authorized to do so, 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 ACKNOWLEDGEMENT STATE OF COUNTY OF On me (Name of Notary) known personally to me to be the same person(s)