Application For Exemption From Registration Requirements As A Franchisor

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF BUSINESS REGULATION SECURITIES DIVISION 1511 PONTIAC AVENUE, JOHN O. PASTORE COMPLEX BLDG 69-1 CRANSTON, RI 02920 APPLICATION FOR EXEMPTION FROM REGISTRATION REQUIREMENTS AS A FRANCHISOR FILING FEE: FISCAL YEAR END: $360.00 EIN# 1. Name of Franchisor: 2. Principal Address: 3. Reason for claim of exemption: 1. 2. Net Worth $10 million and 25 locations for the entire 5-year period preceding the offer. Other: 4. Enclosed documents: 1. 2. 3. 4. 5. 6. 7. 8. Uniform Franchise Offering Circular Uniform Consent to Service of Process Corporate Acknowledgement Certification Page Salesman Disclosure Form Auditor's Consent Guarantee of Performance (when required) Tax Payer Status Affidavit CONSENT TO SERVICE OF PROCESS FRANCHISE EXEMPT PAGE 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com , (a corporation organized under the laws of the state of ) (a partnership) (an individual) , irrevocably appoints the Director of the Rhode Island Department of Business Regulation and the successors in office, its attorney, in the state of Rhode Island for service of notice, process or pleading in an action or proceeding against it arising out of or in connection with the sale of franchises, or a violation of the franchise law of Rhode Island, and consents that an action or proceeding against it may be commenced in a court of competent jurisdiction and proper venue within Rhode Island by service of process upon this officer with the same effect as if the undersigned was organized or created under the law of Rhode Island and had lawfully been served with process in Rhode Island. It is requested that a copy of any notice, process or pleading served this consent be mailed to: Dated: , 20 . By (SEAL) Title By Title CORPORATE ACKNOWLEDGMENT STATE OF COUNTY OF On this day of ) ) ss. ) ,20 , before me FRANCHISE EXEMPT PAGE 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com , the undersigned officer, personally appeared and to be the the above-named corporation, and and that they, as such , known personally to me , respectively, of officers, being authorized to do so, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by themselves as such officers. IN WITNESS WHEREOF I have hereunto set my hand and official seal. (Notary Public) My commission expires: (NOTARIAL SEAL) INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGEMENT STATE OF COUNTY OF On this (Name of Notary) , known personally to me to be the same person(s) whose names(s) is (are) signed to the foregoing instrument, and acknowledged the execution thereof for the uses and purposes therein set forth. IN WITNESS WHEREOF I have hereunto set my hand and official seal. (Notary Public) My commission expires day of ) ) ss. ) ,20 , before me , the undersigned officer, personally appeared (NOTARIAL SEAL) CERTIFICATION I certify under penalty of law that I have read and know the contents of this application by and the and documents that the attached as exhibits in all and incorporated reference statements these FRANCHISE EXEMPT PAGE 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com documents are true and correct. Executed at , , 20 Signature(s) of Franchisor and/or Subfranchisor By (Seal) STATE OF COUNTY OF Personally appeared before me this above-named executed the foregoing Title ) ) ) ss. day of be the , 20 the and known to person(s) who and application (as ____ _________respectively, of the above-named applicant) and (each), being first duly sworn, stated upon oath that said application, and all exhibits submitted herewith, are true and correct. SALESMEN DISCLOSURE FORM 1. As required by Rhode Island statute, list the persons 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: FRANCHISE EXEMPT PAGE 4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com C. Home address and telephone number: D. Present employer: E. Present title: F. G. H. Social Security number: Birth date: 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 the person identified in 1 above: A. Has any administrative, civil or criminal action pending against him alleging a violation of any franchise law, business opportunity law, securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? YES B. NO Has been convicted of a felony or pleaded nolo contendere to a felony charge? C. Has during the 10 year period immediately preceding the date of the offering circular: (1) been convicted or a misdemeanor or pleaded nolo contendere to a misdemeanor charge or been held liable in a civil action by final judgment if such misdemeanor or civil action involved a violation of any franchise law, business opportunity law, securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation or property or any comparable violation of law? YES (2) NO entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, business opportunity, securities, anti-trust, monopoly, trade practice, or trade regulation? YES NO FRANCHISE EXEMPT PAGE 5 of 9 American LegalNet, Inc. www.FormsWorkFlow.com (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 D. With respect to each question above answered "YES" state: (1) (2) (3) (4) (5) the name of each person or entity involved; the court, agency, association or exchange involved; a summary of the allegations; if applicable, the date of the conviction, judgement, decree, order or assurance; and the penalty imposed, damages assessed and nature thereof, and terms and conditions of the judgment, decree, order or assurance. GUARANTEE OF PERFORMANCE For value received located at (Address) absolutely and unconditionally guarantees the performance by , , located at (Address) of all the obligations of under its franchise registration in the state of state or province) dated (Effective date of renewal) (Name of