Application To Register Business Opportunity Investment With Connecticut Banking Commissioner {CT BOIA-1}

Connecticut Form CT BOIA-1 Application to Register Business Opportunity WHERE TO FILE THIS APPLICATION State of Connecticut Department of Banking, Securities and Business Investments Division 260 Constitution Plaza, Hartford, Connecticut 06103. Phone: 860-240-8230. Fax: 860-240-8295. INITIAL REGISTRATION CHECKLIST (see separate instructions for post-sale registration) $400 filing fee payable to "Treasurer, State of Connecticut" Application form Consent to Service of Process (Form CBOIA-2) Disclosure document. Sellers complying with 16 C.F.R. §436 have three filing format choices (subject to additional state required disclosures) between July 1, 2007 and July 1, 2008 with respect to their Connecticut disclosure document: 1) use the former disclosure format provided in 16 C.F.R. §436; 2) use the disclosure format as revised by the Federal Trade Commission in 2007; or 3) rely on the Uniform Franchise Offering Circular (UFOC) Guidelines. Financial statements consisting of 1) the seller's unaudited or audited balance sheet, income statement and statement of changes in financial condition as of a date not more than 4 months prior to the filing of this Application (if the seller has been in business for less than 12 months, the financial statements must be reviewed by an independent CPA); 2) the seller's audited balance sheet, income statement and statement of changes in financial position for the most recent fiscal year; and 3) a balance sheet and income statement and statement of changes in financial position for the prior 2 fiscal years reviewed by an independent CPA Copy of any contracts, agreements, brochures or other documents relating to the business opportunity If required by C.G.S. §36b-64, evidence of surety bond coverage or trust account RENEWAL REGISTRATION CHECKLIST $100 filing fee payable to "Treasurer, State of Connecticut" Updated Application form Disclosure document. Marked to show changes from the disclosure document previously filed. If no changes were made, include an affidavit to that effect. Financial statements required by Section 36b-62(b)(4)(H) of the Connecticut Business Opportunity Investment Act (see above for requirements) American LegalNet, Inc. www.FormsWorkFlow.com Print Form Clear Form INFORMATION ON THE SELLER 1. Official name of seller Address of seller Principal place of business of seller 2. Official name, address and principal place of business of the seller's parent firm or holding company, if any 3. Address of seller's principal office in this state and any other locations in Connecticut 4. Person to whom communications regarding this application should be directed Name Firm or company Address Phone number Fax Number E-mail INFORMATION ON THE SELLER'S BUSINESS EXPERIENCE AND THE BUSINESS OPPORTUNITY BEING OFFERED If the information required by this Item is contained in the disclosure document, reference the disclosure document page(s) and section(s) in the space provided. Otherwise, complete in full, attaching additional sheets as needed. Description Disclosure Document Page and Section Response (if not otherwise in disclosure document) Business experience stated individually of each of the seller's directors, officers or similarly situated individuals, including biographical data concerning these individuals 2 American LegalNet, Inc. www.FormsWorkFlow.com Description Disclosure Document Page and Section Response (if not otherwise in disclosure document) Business experience of the seller, including how long the seller conducted a business of the type to be operated by the purchaser-investor, has granted business opportunities for such business, and has granted business opportunities in other lines of business Factual description of the business opportunities to be offered and sold, and the services, training and assistance that the seller will provide to the purchaser-investor Describe any services, supplies, products, signs, fixtures or equipment relating to the establishment or the operation of the business opportunity that the purchaser-investor is required to purchase, lease or rent directly or indirectly from the seller 3 American LegalNet, Inc. www.FormsWorkFlow.com ACTIVITY IN OTHER JURISDICTIONS 1. List other states in which business opportunities will be offered for sale to public 2. List the states in which business opportunities are eligible for sale to the public 3. List of states, if any, that have refused, by order or otherwise, to authorize the sale of business opportunities to the public, or have revoked, or suspended the right to sell business opportunities, or in which an application has been withdrawn SURETY BOND/TRUST ACCOUNT Is the seller required to obtain a surety bond or establish a trust account under Section 36b-64 of the Connecticut Business Opportunity Investment Act? Yes No CONNECTICUT ACTIVITY 1. Have any business opportunity sales been made in or from Connecticut prior to the date of this Application? Yes No If so, provide the names, addresses and telephone numbers of purchaser-investors, the dates of purchase, amounts invested and the names of those persons who effected the sales on behalf of the seller (attach additional sheets if needed) 2. Have any monies been accepted from prospective purchaser-investors or has the seller entered into any agreements with any prospective Connecticut purchaser-investors? Yes No If so, provide the names, addresses and telephone numbers of all prospective Connecticut purchaser-investors from whom monies were accepted or with whom the seller entered into any such agreements and the names of all individuals who acted on behalf of the seller in communicating with prospective purchaser-investors in connection with such activity. Include copies of all such signed agreements. FISCAL YEAR END What is the seller's fiscal year end? Use month/day format. Examples: 12/31; 6/30; 4/30 Do not use month/year. 4 American LegalNet, Inc. www.FormsWorkFlow.com UNDERTAKINGS The applicant hereby applies for registration or acceptance for filing under the Connecticut Business Opportunity Investment Act of the business opportunity described herein, and in consideration thereof agrees so long as the registration remains in effect that it will: (1) Advise the Commissioner of any change in any of the information contained herein or in any of the documents submitted with or as a part of the application, and amend the disclosure document to show such changes; (2) Notify the Commissioner immediately upon