STATE OF NEW YORK DEPARTMENT OF LAW BUREAU OF INVESTOR PROTECTION AND SECURITIES NYF-6 1-81 APPLICATION EXEMPTION FORM _________________________ Franchisor _____________________ Street Address _________________________ City, State Zip Code _____________________ Telephone Number ______________________________________ hereby submits certified copies of its most recent audited balance sheet and profit and loss statement, attached hereto and mark as Exhibit A, and hereby certifies that. 1. The franchisor, according to the statement submitted, has a net worth of not less than five millon dollars or if its net worth is less than 5 million dollars and more than one million dollars, the franchisor is 80% owned by ____________________________________ which has a net worth, on a consolidated basis, of not less than five million dollars as reflected by its most recent audited balance sheet and profit and loss statement, which is attached hereto and marked as Exhibit B. 2. The identity and business experience in the detail required by Section 200.4 subdivision (iii), paragraphs 2 through 4 of these regulations of persons affiliated with the franchisor is as follows: (attach rider) 3. The franchisor will comply with the provisions of Section 684.2 (c) of the General Business Law. 4. Annexed hereto as Exhibit is a Consent to Service of Process (NYF-5). 5. This application is made for an exemption pursuant to Section 684.2 of the General Business Law. ________________________________ Signature of Franchisor (SEAL) By_______________________________ _________________________________ Title Sworn to before me this day of , 20 ____________________________ NOTARY PUBLIC 2002 © American LegalNet, Inc.