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Franchise Registration Application - Washington
| Franchise Registration Application Form. This is a Washington form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF WASHINGTON DEPARTMENT OF FINANCIAL INSTITUTIONS SECURITIES DIVISION PO Box 9033 Olympia, WA 98501-9033 FOR VALIDATION ONLY 001-080-238-0001 (360) 902-8760 FRANCHISE REGISTRATION APPLICATION APPLICATION FOR (check only one): FILE NO. _________________________________________________ REGISTRATION OF AN OFFER OR INSERT FILE NO. OF PREVIOUS FILINGS OF APPLICANT, IF ANY SALE OF FRANCHISES $600.00 _________________________________________________ FEE (To be enclosed by applicant at time application is initially filed) ______________________________________________________ REGISTRATION RENEWAL STATEMENT OR ANNUAL REPORT $100.00 DATE OF APPLICATION POST-EFFECTIVE AMENDMENT#__________ PRE-EFFECTIVE AMENDMENT # __________ 1. NAME OF FRANCHISOR _______________________________________________________________________ DBA (if applicable ___________________________________________________________________________ NAME UNDER WHICH THE FRANCHISOR IS DOING OR INTENDS TO DO BUSINESS ___________________ ______________________________________________________________________________________________2. FRANCHISORS PRINCIPAL BUSINESS ADDRESS ___________________________________________________ ______________________________________________________________________________________________ TELEPHONE NUMBER __________________________________________________________________________3. NAME OF PERSON TO WHOM COMMUNICATIONS REGARDING THIS APPLICATION SHOULD BE DIRECTED ____________________________________________________________________________________ ADDRESS _____________________________________________________________________________________ TELEPHONE NUMBER __________________________________________________________________________4. NAME OF FRANCHISORS AGENT AUTHORIZED TO RECEIVE PROCESS _____________________________ _____________________________________________________________________________________________ ADDRESS ____________________________________________________________________________________ IN THE STATE OF ______________________________________________________________________________5. NAME OF SUBFRANCHISORS, IF ANY FOR THIS STATE ____________________________________________ ______________________________________________________________________________________________ ADDRESS _____________________________________________________________________________________ TELEPHONE NUMBER __________________________________________________________________________SC-610-225 FRANCHISE APP (R/7/5 Page 1 of 20 <<<<<<<<<********>>>>>>>>>>>>> 2 UNIFORM CONSENT TO SERVICE OF PROCESS KNOW ALL MEN BY THESE PRESENTS: That the undersigned, __________________________________________________ __________________________(a corporation) (a partnership) organized under the laws of the stat e of ____________________________(an individual) (_________________________________), for the purpose of complying with the laws of the state of (Other) Washington relating to the registration, exemption from registration or sale of franchises, hereby irrevocably appoints theAdministrator of Securities, and the successors in such office, its atto rney in the state of Washington upon whom may beserved any notice, process, or pleading in any action or proceeding against it arising out of or in connection with the saleof franchises, or out of violation of the aforesaid laws of said state; and the undersigned does hereby consent that anysuch action or proceeding against it may be commenced in any court of co mpetent jurisdiction and proper venue withinsaid state by service of process upon said officer with the same effect as if the undersigned was organized or createdunder the laws of said state and had lawfully been served with process i n said state. It is requested that a copy of any notice, process, or pleading served h ereunder by mailed to (Name and Address:________________________________________________________________________ _________________ DATED: ___________________________________________, 20 ___ BY: _____________________________________________________ SEAL TITLE: ____________________________________________________ BY: _____________________________________________________ TITLE: ___________________________________________________ CORPORATE ACKNOWLEDGMENT STATE OF ______________________ COUNTY OF ____________________ On this _________ day of _____________, 20 ___, before me personally appearedSS. _____________________________________ to me known personally to be the (president, vice president, secretary, treasurer, or other authorized officeror agent, as the case may be) of the corporation that executed the with in and foregoing instrument, andacknowledged said instrument to be the free and voluntary act and deed o f said corporation, for the uses andpurposes therein mentioned, and on oath stated that s/he was authorized to execute said instrument and thatthe seal affixed in the corporate seal of said corporation. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. ___________________________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES _________________________ NOTARIAL SEAL SC-610-225 FRANCHISE APP (R/7/5 Page 2 of 20 <<<<<<<<<********>>>>>>>>>>>>> 3 INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGMENT STATE OF ______________________ SS. COUNTY OF ____________________ On this _________ day of _____________, 20 ___, before me _____________ _____________________________________ the undersigned officer, personally appeared _______________________________________________________ to me personally known and known to me to be the same person(s) whose name(s) is (are) signed to the foregoing instrument, and acknowledged the execution thereof for the use s and purposes therein set forth. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. __________________________________________________ NOTARIAL SEAL MY COMMISSION EXPIRES: _______________________ NOTARY PUBLIC SIGNATURE PAGE I certify under penalty of law that I have read this application and the exhibits attached hereto and incorporated herein by reference, and know the contents thereto and inco rporated herein by reference, and know the contents thereof and that the statements therein are true and c orrect to the best of my knowledge. Executed at __________________________________, ________________________ ________________, 19 _____. SIGNATURE(S) OF FRANCHISOR AND/OR SUBFRANCHISOR ________________________________________ _____________
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