Uniform Franchise Registration Application {Form A}

(Insert File number of immediately preceding filing of Applicant) State: Fee: APPLICATION FOR (Check only one): INITIAL REGISTRATION OF AN OFFER AND SALE OF FRANCHISES RENEWAL APPLICATION OR ANNUAL REPORT POST-EFFECTIVE MATERIAL AMENDMENT 1.Full legal name of Franchisor:2.Name of the franchise offering:3.Franchisor=s principal business address:4.Name and address of Franchisor=s agent in this State authorized to receive service ofprocess:5.The states in which this application is or will be shortly on file:6.Name, address, telephone and facsimile numbers, and e-mail address of person to whomcommunications regarding this application should be directed: Franchise registration forms, statutes, regulations and guidelines can be downloaded from www.ag.ny.govUNIFORM FRANCHISE REGISTRATION APPLICATION File No. Certification I certify and swear under penalty of law that I have read and know the contents of this application, including the Franchise Disclosure Document with an issuance date of attached as an exhibit, and that all material facts stated in all those documents are accurate and those documents do not contain any material omissions. I further certify that I am duly authorized to make this certification on behalf of the Franchisor and that I do so upon my personal knowledge. Signed at , on , 20 Franchisor: By: Print Name: Title: STATE OF) ) Name of Entity COUNTY OF ) Personally appeared before me this day of , 20, the above-named , to me known to be the person who executed the foregoing application (as of the above name applicant) and, after being administered an oath and duly sworn, swore upon oath that said application, and all exhibits submitted herewith, are true and correct. Notary Public (NOTARIAL SEAL) My Commission Expires: Instruction for Preparing Form A - Uniform Franchise Registration Application 1.Insert the name of the state where the filing is to be made in the first line.2.For franchisors previously registered, insert the file number of the immediatelypreceding filing of the applicant in AFile No.@3.Fill in the amount of the filing fee. A check in U.S. funds drawn on a U.S. bank mustaccompany the application.4.Check one of the lines in the AApplication For@ section to indicate the type of filing.5.Line 1: Insert the full legal name of the franchisor.6.Line 2: Insert the trade name of the franchise being offered.7.Line 3: Insert the franchisor=s principal business address in the U.S. If aforeign franchisor does not have a U.S. business address, insert its principal business address in its home jurisdiction. 8.Line 4: Insert the name and address of the franchisor=s agent in the state authorized toreceive service of process. You should list the appropriate state authority listed in Form C(if required by the Franchise Filing State). You may also list additional agents for serviceof process that have been duly appointed by the franchisor.9.Line 5: Insert the Franchise Filing States in which the application will be filed.10.Line 6: Insert the names, address, telephone and facsimile numbers, and e-mailaddress of the person to whom communications regarding the Application should bedirected. Identify only one individual. Confirmation of effectiveness will be sent to thisaddress.11.Certification: Insert the issuance date of the disclosure document, the city and state inwhich the Application was signed, and the date of signing. Insert the franchisor=s name inthe signature block and print or type the name and title of the authorized signer. Theauthorized signer should sign on the ABy:@ line.12.Complete and sign the jurat.