Business Opportunity Consumer Statement

ILLINOIS SECURITIES DEPARTMENT BUSINESS OPPORTUNITY CONSUMER STATEMENT Illinois Securities Department Illinois Securities DepartmentEnforcement Division Enforcement DivisionLincoln Tower Suite 200 Suite 1220520 South Second Street 69 West Washington StreetSpringfield, IL 62701 Chicago, IL 60602(217) 782-2256 (312) 793-3384Toll Free (800) 628-7937 By completing this statement you will be assisting the Illinois SecuritiesDepartment with the inquiry of a Business Opportunities Company and/or Seller.The information received will enable the Illinois Securities Department to conduct amore accurate inquiry. CONSUMER INFORMATION: Name:______________________________________________ Age_____ Address:______________________________________________________________City:____________________________State:_______Zip Code:__________________Home Telephone:____________________Work Telephone:_____________________Please indicate the most convenient day and time to be contacted: M T W TH FAt Work:________________At Home:_______________Time:_____________(am/pm)COMPANY INFORMATION: Name, address, telephone number and title (if known) of each person who offered or soldyou the business opportunity: _____________________________________________________________________<<<<<<<<<********>>>>>>>>>>>>> 2_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ CONTACT: Was the business opportunity offered or sold at a fair or trade show? Y es __ No __ If Yes, please indicate the location of the fair or show and date. _________________________________ __________________________ Location DateDid you respond to advertisement based on a televised infomercial or rad io broadcast? Yes __ No __ If yes, please indicate the station and date. _________________________________ __________________________ Station DateDid you respond to a newspaper or magazine advertisement? Yes __ No __ If yes, please indicate the publication and the approximate date of its publication. _________________________________ __________________________ PublicatioDaten Did the company or its representative contact you by telephone? Yes __ No __ If yes, please indicate the name of the person and the approximate date. _________________________________ __________________________ NameDate Did you become informed of the business opportunity via the Internet? Y es __ No __ If yes, please indicate the internet address of the company (if it is k nown) and approximatedate. (Attach copy of Internet page if available.) _________________________________ __________________________ Internet Address DateIf contacted by other means, please indicate the type of contact. _____________________________________________________________________ - 2 - <<<<<<<<<********>>>>>>>>>>>>> 3_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ DID YOU RECEIVE A WRITTEN CONTACT OR OTHER MATERIALS? Yes __ No __ DID YOU RECEIVE A DISCLOSURE DOCUMENT BEFORE PURCHASING THE BUSINESS OPPORTUNITY? Yes __ No __DESCRIBE THE BUSINESS OPPORTUNITY: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ AMOUNT AND FORM OF PAYMENT: Amount of initial payment $______________ Date payment made _______________ Did you pay by: Cash _____________ Credit Card ___________________________ Promissory Note/or Other Obligation to Pay _________________________________ Check _____________ Amount ______________ Check Number ________________ Other Form of Payment __________________________________________________ After the initial payment, were you required to make any additional payments? Yes __ No __ If yes, what is the amount and the frequency of the payments? Amount ______________ Number of Payments __________________________ Were these additional payments or fees disclosed in the original contact or agreement?Yes __ No __ - 3 - <<<<<<<<<********>>>>>>>>>>>>> 4MISCELLANEOUS QUESTIONS: Have you filed an inquiry or complaint with the company, Better Business Bureau, or anyother person or governmental agency? If yes, please indicate when and the name andaddress of the person or agency _______________________________ ________________________________ Name Address ________________________________ AddressDate ___________________________ Telephone Number______________________What, if any, action has been taken? _____________________________________________________________________ Have you obtained private legal counsel? Yes__ No__ If yes, please giv e the attorneysname, business address and telephone number. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Telephone Number:_____________________________ PLEASE ATTACH COPIES OF ANY PAPERS REGARDING THE BUSINESS OPPORTUNITY THAT WAS EITHER OFFERED OR SOLD TO YOU (including the front and back of all canceled checks). Are you willing to be interviewed by a Department investigator? Yes__ No__ Are you willing to testify if formal proceedings are commenced? Yes__ No__ PLEASE DESCRIBE IN DETAIL THE REASON FOR FILING THIS STATEMENT: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _______________________________________ SIGNATURE OF CONSUMER - 4 -