Salesman Disclosure Form

State of Was h ington SECURITIES DIVISION Department of Financial Institutions P.O. Box 9033 Olympia, WA 98509033 36 0-902-876 0 SALESMAN DISCLOSURE FORM 1. As required by this States statute, list the person who will engage in the offer or sale of franchises in this state and for each person list the following information: A. Name; B. Business address and telephone number; C. Home address and telephone number; D. Present employer; E. Present title; F. Birthdate; and G. Employment or occupation during the past 5 years. For each such employment state the name of the employer, position held, and beginning and ending dates for each such employment. 2. State whether any person identified in 1. Above: A. Has any administrative, civil, or criminal action pending against him alleging a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? Yes No B. Has during the 10 year period immediately preceding the date of the offering circular: 1) been convicted of a felony or pleaded nolo contendere to a felony charge or been held liable in a civil action by final judgment if such felony or civil action involved a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable violations of law? Yes No 2) entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, securities, antitrust, monopoly, trade practice, or trade regulation law? Yes No 3) been subject to any order of any national securities association or national securities exchange (as defined in the Securities and Exchange Act of 1934) suspending or expelling such person from membership in such association or exchange. Yes No C. With respect to each question above answered Yes state: 1) the name of each person or entity involved; 2) the court, agency, association, or exchange involved; S C-610-261 SALES MAN DIS FOR M (N/1/92)M American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 3) a summary of the allegations; 4) if applicable, the date of the conviction, judgment, decree, order, or assurance; and 5) the penalty imposed, damages assessed, and nature thereof, terms and conditions of judgment, decree, order, or assurance. **DFI takes steps to protect the confidentiality of personal information, to the extent permitted by law. Howeve r, all information collected by DFI becomes a public record and may be subject to insp ection and copying by the public, unless an exemption or other protection in law exists . A copy of our privacy policy is available upon request. American LegalNet, Inc. www.USCourtForms.com