PO Box 9033 Olympia WA 98507-9033 360-902-8760 www.wa.gov/dfi/securities Securities Division APPLICATION FOR A FRANCHISE BROKER LICENSE Initial Application ($50 Fee) Renewal Application ($25 Fee) NAME OF FIRM OR INDIVIDUAL Re-Application ($50 Fee) Amendment (No Fee) File #: (if known)_______________ D.B.A. APPLICANT ADDRESS CITY STATE/PROVINCE ZIP BUSINESS WEBSITE DATE AND STATE OF ORGANIZATION OR BIRTHDATE (Individual) PHONE E-MAIL ADDRESS NAME AND ADDRESS AND TELEPHONE NUMBER OF PERSON TO WHOM COMMUNICATIONS REGARDING THIS APPLICATION SHOULD BE DIRECTED: NAME ADDRESS CITY STATE/PROVINCE ZIP PHONE IMPORTANT NOTICE No person shall act as a franchise broker in this state until licensed by the Securities Division. 1. Attached hereto are the following exhibits: a. ! Check ! Money Order ! Online Payment (no exhibit required) in the amount of $____ payable to the State Treasurer. b. An irrevocable consent to service of process pursuant to RCW 19.100.160. c. Broker and Principal disclosure page. d. Broker and Principal employment history. e. A BALANCE SHEET PREPARED IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES AND AS OF A DATE WITHIN 90 DAYS OF THE APPLICATION. NOTICE REGARDING AMENDMENT REQUIREMENTS If there are any material changes that affect the application, a new application should be promptly submitted (no fee). FRANCHISE BROKER LICENSES EXPIRE ANNUALLY AT THE END OF THE CALENDAR YEAR An application for a franchise broker license should be submitted approximately fifteen business days prior to the end of the year with the renewal fee of $25.00 in order to avoid a lapse in your license. 2. 3. The undersigned applicant certifies under penalty of perjury under the laws of the State of Washington that the information and responses made in this application are true and correct: _____________________________________ DATE __________________________________________________ BROKER OR PRINCIPAL SIGNATURE __________________________________________________ PRINT NAME OR TITLE Note: DFI takes steps to protect the confidentiality of personal information, to the extent permitted by law. However, all information collected by DFI becomes a public record and may be subject to inspection 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.FormsWorkFlow.com SC-610-074 FRANCHISE BROKER CERTIFICATE (Revised 12/2014) Page 1 of 5 POWER OF ATTORNEY FOR CONSENT TO SERV KNOW ALL PERSONS BY THESE PRESENTS: That __________________________________________________ of __________________________________________________, NAME a company, corporation, association, joint stock company, co-partnership, trustee or individual (strike words not applicable), _____________________________________________________________________________, in accordance with the provisions CITY STATE of Chapter 19.100 RCW and particularly RCW 19.100.160, Franchise Investment Act of Washington, does hereby make and give this irrevocable written consent that in suits, proceedings and actions arising out of our founded upon the sale of franchises within the State of Washington, the service on the Administrator of Securities of any notice, process or pleading therein shall be as valid and binding as if due service had been made on said entity or individual. IN WITNESS WHEREOF, the said ____________________________________, a company, corporation, association, joint stock company, co-partnership, trustee, individual, (strike words not applicable), has hereunto affixed signatures thereof authorizing the same and has caused these presents to be executed by the President and Secretary, and authenticated by the corporate seal thereof, the _______ day of _______________, A.D. 20____, in accordance with the resolution of the Board of Directors (trustees or managers of the corporation or association) thereof authorizing the same. _____________________________________________________ (SIGNATURE OF APPLICANT) Attest:__________________________________________ By __________________________________________________ (SECRETARY) (PRESIDENT, TRUSTEE, OR MANAGER) _______________________________________________ (INDIVIDUAL) It is requested that a copy of any notice, process or pleading served hereunder be mailed to: NAME _____________________________________________________________________________________________________ ADDRESS __________________________________________________________________________________________________ State of _________________________ County of _______________________ On this ______ day of __________, A.D. 20 _____, before me personally appeared ___________________________________, President, vice-president, secretary, or other title of the Corporation whose name is subscribed to the foregoing instrument, that the seal affixed thereto is the seal of said corporation, and that the instrument was signed and sealed on behalf of said corporation by authority of its Board of Directors, and the said _______________________ and acknowledged to me that they executed the same as their free and voluntary act and deed of such corporation, for the uses and purposes therein set forth. Given under my hand and seal of the office the day and year last above written. (OFFICIAL SEAL) _____________________________________________________ Notary Public in and for the State of _______________________ Residing in ___________________________________________ INDIVIDUAL ACKNOWLEDGMENT State of _________________________ County of _______________________ On this ______ day of __________, A.D. 20 _____, before me personally appeared ___________________________________ to me known to the identical person...named in and who executed the foregoing instrument, and acknowledged to me that ___________________ executed the same as ________________ free and voluntary act and deed for the uses and purposes herein set forth Given under my hand and seal the day and year last above written. ________________________________________________________ (OFFICIAL SEAL) Notary Public in and for the State of __________________________ Residing in ______________________________________________ CORPORATE ACKNOWLEDGMENT SC-610-074 FRANCHISE BROKER CERTIFICATE (Revised 12/2014) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com BROKER AND PRINCIPAL LITIGATION DISCLOSURE 1. Has the broker or any of the broker's principals, officers or directors ever been