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Uniform Franchise Registration Application Form A - New York

Uniform Franchise Registration Application Form. This is a New York form and can be used in Investor Protection And Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 3/15/2012
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STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL ERIC T. SCHNEIDERMAN ATTORNEY GENERAL Franchise registration forms, statutes, regulations and guidelines can be downloaded from www.ag.ny.gov UNIFORM FRANCHISE REGISTRATION APPLICATION File No. (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 of process: 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 whom communications regarding this application should be directed: American LegalNet, Inc. www.FormsWorkFlow.com 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____________) ) COUNTY OF __________) Name of Entity________________ 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: ________________ American LegalNet, Inc. www.FormsWorkFlow.com 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 immediately preceding 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 must accompany 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 a foreign 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 to receive 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 service of 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-mail address of the person to whom communications regarding the Application should be directed. Identify only one individual. Confirmation of effectiveness will be sent to this address. 11. Certification: Insert the issuance date of the disclosure document, the city and state in which the Application was signed, and the date of signing. Insert the franchisor=s name in the signature block and print or type the name and title of the authorized signer. The authorized signer should sign on the ABy:@ line. 12. Complete and sign the jurat. American LegalNet, Inc. www.FormsWorkFlow.com
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