Franchise Broker Registration Form {Form I}

Form I - Franchise Broker Registration FormFRANCHISE BROKER REGISTRATION FORM FEE:$150.00 (To be enclosed by Applicant at time application is filed)1.Name of Franchise Broker:2.Franchise Broker222s principal business address and telephone number:3.State whether the Franchise Broker:A.Has an administrative, criminal or material civil action pending againstthat person alleging a violation of franchise, antitrust or securities law, oralleging fraud, unfair or deceptive practices, or any comparableallegations?Yes No If you answered 223yes224, please provide:1.Names of the parties:2.Forum, nature and current status of the pending action:3.Case or proceeding identification number:B.Has ever been convicted of or pleaded nolo contendere to a felonycharge; or been held liable or enjoined in a civil action by final judgmentor been the subject of a material action involving an alleged violation of afranchise, antitrust or securities law, or allegations of fraud, fraudulentconversion or misappropriation of property, unfair or deceptive practices,or comparable allegations?Yes No If you answered 223yes224, please provide:1.Names of the parties:2.The forum:3.Case or proceeding identification number: American LegalNet, Inc. www.FormsWorkFlow.com C.Is subject to a currently effective injunction or restrictive order or decreeresulting from a pending or concluded action brought by a public agencyand relating to the franchise, or to a Federal, State or Canadian franchise,securities, antitrust, trade regulation or trade practice law.Yes No If you answered 223yes224, please provide:1.Name of the person:2.Public agency or court:3.Case or proceeding identification number:4.Franchise Broker designates the New York Secretary of State as agent to receiveprocess in its Consent to Service of Process, a copy of which is enclosed. Franchise Broker:By:Name:Title:STATE OF ) ) 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 anoath and duly sworn, swore upon oath that said application, and all exhibits submitted herewith,are true and correct.Notary Public My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Preparing Form I - Franchise Broker Registration Form1.Insert the name of the Franchise Broker and any name under which the FranchiseBroker is doing or intends to do business. 2.Insert the Franchise Broker222s principal address and telephone number.3.Answer 223Yes224 or 223No224 to each question (A, B and C). If the answer is 223Yes224 to anyquestion, provide the requested additional information. For purposes of 3(B)., 223holdliable224 means that, as a result of claims or counterclaims, the person must pay money orother consideration, must reduce an indebtedness by the amount of an award cannotenforce its rights, or must take action adverse to its interest. Accordingly, dismissalsconcluding an adversary proceeding need not disclosed, but a settlement resolving anadversary proceeding must be disclosed if the person is held liable as defined above.4.Include a copy of the Consent to Service of Process, designating New York222sSecretary of State as agent to receive process.5.Complete and sign the jurat6.If a Franchise Broker is no longer soliciting or offering or selling franchises on behalfof the Franchisor, promptly notify the Department of Law by letter of the termination ofthat relationship. American LegalNet, Inc. www.FormsWorkFlow.com