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Application To Register Business Opportunity Investment With Connecticut Banking Commissioner Form. This is a Connecticut form and can be use in Blue Sky Secretary Of State.
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Connecticut Form CT BOIA-1
Application to Register Business Opportunity
WHERE TO FILE THIS APPLICATION
State of Connecticut Department of Banking, Securities and Business Investments Division
260 Constitution Plaza, Hartford, Connecticut 06103. Phone: 860-240-8230. Fax: 860-240-8295.
INITIAL REGISTRATION CHECKLIST (see separate instructions for post-sale registration)
$400 filing fee payable to “Treasurer, State of Connecticut”
Application form
Consent to Service of Process (Form CBOIA-2)
Disclosure document. Sellers complying with 16 C.F.R. §436 have three filing format choices
(subject to additional state required disclosures) between July 1, 2007 and July 1, 2008 with
respect to their Connecticut disclosure document: 1) use the former disclosure format provided in
16 C.F.R. §436; 2) use the disclosure format as revised by the Federal Trade Commission in
2007; or 3) rely on the Uniform Franchise Offering Circular (UFOC) Guidelines.
Financial statements consisting of 1) the seller's unaudited or audited balance sheet, income
statement and statement of changes in financial condition as of a date not more than 4 months
prior to the filing of this Application (if the seller has been in business for less than 12 months, the
financial statements must be reviewed by an independent CPA); 2) the seller's audited balance
sheet, income statement and statement of changes in financial position for the most recent fiscal
year; and 3) a balance sheet and income statement and statement of changes in financial
position for the prior 2 fiscal years reviewed by an independent CPA
Copy of any contracts, agreements, brochures or other documents relating to the business
opportunity
If required by C.G.S. §36b-64, evidence of surety bond coverage or trust account
RENEWAL REGISTRATION CHECKLIST
$100 filing fee payable to “Treasurer, State of Connecticut”
Updated Application form
Disclosure document. Marked to show changes from the disclosure document previously filed. If
no changes were made, include an affidavit to that effect.
Financial statements required by Section 36b-65(b) of the Connecticut Business Opportunity
Investment Act (see above for requirements)
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INFORMATION ON THE SELLER
1.
Official name of seller
Address of seller
Principal place of business of seller
2.
Official name, address and principal place of business of the seller's parent firm or holding
company, if any
3.
Address of seller’s principal office in this state and any other locations in Connecticut
4.
Person to whom communications regarding this application should be directed
Name
Firm or company
Address
Phone number
Fax Number
E-mail
INFORMATION ON THE SELLER’S BUSINESS EXPERIENCE AND THE BUSINESS
OPPORTUNITY BEING OFFERED
If the information required by this Item is contained in the disclosure document, reference the disclosure
document page(s) and section(s) in the space provided. Otherwise, complete in full, attaching additional
sheets as needed.
Description
Disclosure Document Page
and Section
Response (if not otherwise in
disclosure document)
Business experience stated
individually of each of the seller's
directors, officers or similarly
situated individuals, including
biographical data concerning
these individuals
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Description
Disclosure Document Page
and Section
Response (if not otherwise
in disclosure document)
Business experience of the
seller, including how long the
seller conducted a business of
the type to be operated by the
purchaser-investor, has granted
business opportunities for such
business, and has granted
business opportunities in other
lines of business
Factual description of the
business opportunities to be
offered and sold, and the
services, training and assistance
that the seller will provide to the
purchaser-investor
Describe any services, supplies,
products, signs, fixtures or
equipment relating to the
establishment or the operation of
the business opportunity that the
purchaser-investor is required to
purchase, lease or rent directly or
indirectly from the seller
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ACTIVITY IN OTHER JURISDICTIONS
1.
List other states in which business opportunities will be offered for sale to public
2.
List the states in which business opportunities are eligible for sale to the public
3.
List of states, if any, that have refused, by order or otherwise, to authorize the sale of business
opportunities to the public, or have revoked, or suspended the right to sell business opportunities,
or in which an application has been withdrawn
SURETY BOND/TRUST ACCOUNT
Is the seller required to obtain a surety bond or establish a trust account under Section 36b-64 of
the Connecticut Business Opportunity Investment Act? Yes
No
CONNECTICUT ACTIVITY
1.
Have any business opportunity sales been made in or from Connecticut prior to the date of this
Application?
Yes
No
If so, provide the names, addresses and telephone numbers of purchaser-investors, the dates of
purchase, amounts invested and the names of those persons who effected the sales on behalf of
the seller (attach additional sheets if needed)
2.
Have any monies been accepted from prospective purchaser-investors or has the seller entered
into any agreements with any prospective Connecticut purchaser-investors? Yes
No
If so, provide the names, addresses and telephone numbers of all prospective Connecticut
purchaser-investors from whom monies were accepted or with whom the seller entered into any
such agreements and the names of all individuals who acted on behalf of the seller in
communicating with prospective purchaser-investors in connection with such activity. Include
copies of all such signed agreements.
FISCAL YEAR END
What is the seller’s fiscal year end? Use month/day format. Examples: 12/31; 6/30; 4/30
Do not use month/year.
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UNDERTAKINGS
The applicant hereby applies for registration or acceptance for filing under the Connecticut Business
Opportunity Investment Act of the business opportunity described herein, and in consideration thereof
agrees so long as the registration remains in effect that it will: (1) Advise the Commissioner of any
change in any of the information contained herein or in any of the documents submitted with or as a part
of the application, and amend the disclosure document to show such changes; (2) Notify the
Commissioner immediately upon the receipt of any stop order, denial, order to show cause, suspension
or revocation order, injunction or restraining order, or similar order entered or issued by any state or other
regulatory authority or by any court concerning the business opportunities of the seller currently being
offered to the public; and (3) Furnish promptly all additional information and documents in respect to the
business opportunities covered by the application as may be requested by the Commissioner or the
Commissioner’s duly authorized representative.
SIGNATURE
I certify under penalty of law and on behalf of the business opportunity seller that I have read this
application and the documents filed therewith, including the seller’s disclosure document; that the
statements contained therein are true and correct to the best of my knowledge; and that the seller will
comply with the undertakings contained in this application.
_________________________________________________________
Signature of Executive Officer or individual of similar rank
Print Name of Signatory: ___________________________________
Title: ____________________________________________________
STATE OF
COUNTY OF
On this
day of
20
, before me, the undersigned officer, personally appeared
, to me known (or satisfactorily proven) to be the person who executed
the foregoing application on behalf of the business opportunity seller named herein, and who, being first
duly sworn upon oath, did acknowledge to me that he/she was duly authorized to executed the foregoing
instrument for the purposes therein contained, and that such application and the documents filed therewith,
are true and correct to the best of his/her knowledge.
___________________________________________
Notary Public
My Commission Expires:
Rev. 11/2007
5
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FORM CT BOIA-2
CONSENT TO SERVICE OF PROCESS
•
•
•
•
Pursuant to the Business Opportunity Investment Act, applicants must complete this form
Corporations must fill in Parts I and II
Individuals and partnerships must fill in Parts I and III
Limited liability companies must fill in Parts I and IV
PART I
KNOW ALL MEN BY THESE PRESENTS
That the undersigned _________________________________________ (a corporation) (a
partnership) (a limited liability company) organized under the laws of ______________________ or
(an individual) [strike out inapplicable nomenclature] for the purpose of complying with the laws and
regulations of the State of Connecticut, hereby irrevocably appoints the Banking Commissioner of
the State of Connecticut, and the successors in such office, its attorney in the State of Connecticut
upon whom may be served any notice, process or pleading in any noncriminal suit, action or
proceeding against the seller or the seller’s successor, executor or administrator which arises under
sections 36b-60 to 36b-80, inclusive, of the Connecticut General Statutes or any regulation or order
adopted or issued under said sections, with the same force and validity as if served personally on
the person filing this Consent to Service of Process, and the undersigned does hereby consent that
any such action or proceeding against it may be commenced in any court of competent jurisdiction
and proper venue within said State or in any administrative agency by service of process upon said
officer with the same effect as if the undersigned has lawfully been served with process or notice in
said State.
It is requested that a copy of any notice, process or pleading served hereunder be mailed to:
____________________________________________________________________________
Name
Address
(SEAL)
Dated this _________ day of _______________________________ 20_______
Name of Seller: ______________________________________________________
Signature:
Title of Signatory:
_________________________________________________
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CORPORATE ACKNOWLEDGMENT
PART II
STATE OF
__________________________________
COUNTY OF
____________________________ss: ___________________________
On this the ___________ day of ______________________ 20____, before me, the undersigned
officer, personally appeared _____________________________________________ who
acknowledged himself/herself to be the _______________________ of
________________________________, a corporation, and that he/she, as such, being authorized
so to do, executed the foregoing instrument for the purposes therein contained, by signing the name
of the corporation by himself/herself as _________________________________
IN WITNESS WHEREOF I hereunto set my hand
________________________________
Notary Public
My Commission Expires:
2
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INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGMENT
PART III
STATE OF _____________________________________
COUNTY OF ____________________________________ ss: ________________________
On this _______ day of _______________________, 20______, before me,
________________________________________, the undersigned officer, personally appeared
__________________________________known to me (or satisfactorily proven) to be the same
person whose name is signed to the foregoing instrument, and acknowledged the execution thereof
for the uses and purposes therein set forth.
IN WITNESS WHEREOF I hereunto set my hand.
________________________________
Notary Public
My Commission Expires: ________________
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LIMITED LIABILITY COMPANY ACKNOWLEDGMENT
PART IV
STATE OF ________________________________
COUNTY OF ____________________________ ss: ______________________________
On this the _____ day of _____________________ 20_____, before me,
___________________________________, the undersigned officer, personally appeared
__________________________________ who acknowledged himself/ herself to be the
______________________________ of _________________________________________, a
(member managed or manager managed) limited liability company, and that he/she, as such,
being authorized so to do, executed the foregoing instrument for the purposes therein
contained, by signing the name of the limited liability company by himself/herself as
_____________________.
In witness whereof I hereunto set my hand.
________________________________
Notary Public
My Commission Expires: ________________
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