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) American LegalNet, Inc. www.FormsWorkflow.com 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 2 American LegalNet, Inc. www.FormsWorkflow.com 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 3 American LegalNet, Inc. www.FormsWorkflow.com 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. 4 American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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: _________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 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 American LegalNet, Inc. www.FormsWorkflow.com 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: ________________ 3 American LegalNet, Inc. www.FormsWorkflow.com 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: ________________ 4 American LegalNet, Inc. www.FormsWorkflow.com