STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT GUIDELINES FOR FRANCHISE REGISTRATION DBO ­ 310.111 (Rev. 11-15) Form E - Sales Agent Disclosure Form SALES AGENT DISCLOSURE FORM 1. List the persons who will offer or sell franchises in this state. For each person state: A. Name; B. Business address and telephone number; C. Home address and telephone number; D. Present employer; E. Present title; F. Social Security Number; G. Birthdate; and H. Employment during the past five years. For each employment, state the name of the employer, position held, and beginning and ending dates. 2. State whether any person identified in 1. above: A. Has any administrative, civil or criminal action pending alleging a violation of franchise or securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? B. Had during the ten-year period immediately before the Disclosure Document date: 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 the felony or civil action involved a violation of franchise or securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or comparable violations of law? YES ______ NO ______ American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT GUIDELINES FOR FRANCHISE REGISTRATION DBO ­ 310.111 (Rev. 11-15) 2. entered into or been named in a consent judgment, decree, order or assurance under federal or state franchise, securities, anti-trust, monopoly, trade practice or trade regulation law? YES ______ NO ______ 3. been subject to an order or national securities association or national securities exchange as defined in the Securities and Exchange Act of 1934 suspending or expelling the person from membership in the association or exchange? YES ______NO ______ C. For each above question answered "YES" state: 1. 2. 3. 4. 5. the name of the person or entity involved; the court, agency, association or exchange involved; a summary of the allegations; if applicable, the date of the conviction, judgment, decree, order or assurance; and the penalty imposed, damages assessed, terms and conditions of the judgment, decree, or order or assurance. American LegalNet, Inc. www.FormsWorkFlow.com