Business Opportunity Consumer Statement {SEC 307}

Illinois Secretary of State Securities Department Business Opportunity Consumer Statement 421 E. Capitol Ave., 2nd Floor Springfield, IL 62701 · 217-782-2256 69 W. Washington St., Ste. 1220 Chicago, IL 60602 · 312-793-3384 800-628-7937 By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Business Opportunities Company and/or Seller. The information received will enable the Securities Department to conduct a more accurate inquiry. CONSUMER INFORMATION: Name: Age: Address: City: Home Telephone Number: Please indicate the most convenient day to be contacted: Monday Tuesday Wednesday Thursday Friday Please indicate the most convenient time and place to be contacted: Work (indicate time): Home (indicate time): COMPANY INFORMATION: Name, Title (if known), Address and Telephone Number of each person who offered or sold you the Business Opportunity: Name Name Name Name Title Title Title Title Address Address Address Address Telephone Number Telephone Number Telephone Number Telephone Number State: Work Telephone Number: ZIP: CONTACT: Was the Business Opportunity offered or sold at a fair or trade show? Yes (indicate location of fair or show and date): No Location and Date Did you respond to an advertisement based on a televised infomercial or radio broadcast? Yes (indicate station and date): Station and Date No Did you respond to a newspaper or magazine advertisement? Yes (indicate publication and approximate date): No Did the company or its representative contact you by telephone? Yes (indicate name of person and approximate date): No Publication and Date Publication and Date American LegalNet, Inc. www.FormsWorkFlow.com Printed by authority of the State of Illinois. November 2015 -- 100 -- SEC 307.1 Did you learn about the Business Opportunity via the Internet? Yes (indicate Internet address of company, approximate date -- include a copy of the page if available): No If contact by other means, please indicate type of contact: Internet Address and Date Did you receive a written contact or other written 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: Payment made by: Cash: Credit Card: Promissory Note/or other Obligation to Pay: Check (indicate amount and check number): Other form of payment (please specify): Date Payment Made: After the initial payment, were you required to make any additional payments? Yes (indicate amount, number and frequency of payments): No Were these additional payments or fees disclosed in the original contact or agreement? Yes No American LegalNet, Inc. www.FormsWorkFlow.com MISCELLANEOUS QUESTIONS: Have you filed an inquiry or complaint with the company, the Better Business Bureau or any other person or governmental agency? Yes No If yes, indicate name, address, and telephone number of person or agency and date: What, if any, action has been taken? Have you obtained private legal counsel? Yes No If yes, indicate name, business address and telephone number of attorney: ATTACH COPIES OF ANY PAPERS REGARDING THE BUSINESS OPPORTUNITY THAT WAS EITHER OFFERED OR SOLD TO YOU. (Include the front and back of all canceled checks.) Are you willing to be interviewed by a Securities Department investigator? Yes No Are you willing to testify if formal proceedings are commenced? Yes No DESCRIBE IN DETAIL THE REASON FOR FILING THIS STATEMENT -- IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS: Signature of Consumer Date American LegalNet, Inc. www.FormsWorkFlow.com