NYF-3 1-81 STATE OF NEW YORK Office of the Attorney General BUREAU OF INVESTOR PROTECTION AND SECURITIES FRANCHISE SALES AGENT STATEMENT 1. Firm Name____________________________________________________ 2. Principal Office_____________________________________________ 3. Give the following information with regard to each corporate officer, director, partner or other principal of the franchise sales agent (use additional pages as riders to this form, where necessary): A. Name ____________________________________________________ B. Business Address and telephone number ___________________ _________________________________________________________ C. Home address and telephone number _______________________ _________________________________________________________ D. Present Title ___________________________________________ _________________________________________________________ E. Social Security Number __________________________________ _________________________________________________________ F. Birth date ______________________________________________ G. Employment or occupation during the past 5 years. For each such employment state the name of the employer, position held and beginning and termination dates for each such employment. 2002 © American LegalNet, Inc. 4. State whether any person identified in 1 or 3 above A. Has any administrative, civil or criminal action pending against him alleging a violation of any franchise law, securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? Yes ______. No. ____. Give details in a rider attached to this statement. B. Has (1) been convicted of a felony or pleaded nolo con- tendere to a felony charge or, within the ten year period immediately preceding the application for registration, has been convicted of a misdemeanor or pleaded nolo contendere to a misdemeanor charge or been held liable in a civil action by final judgment or been the subject of a material complaint or other legal proceeding if such misdemeanor conviction or charge or civil action, complaint or other legal proceeding involved violation of any franchise law, securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or comparable allegations. (2) entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, securities, anti-trust, monopoly, trade practice, or trade regulation law? Yes ____ No ____. (3) been subject to any order of any national securities association or national securities exchange (as defined in the Securities and Exchange Act of 1934) suspending or expelling such person from membership in such association or exchange? Yes ___ No ___. C. With respect to each question above answered "Yes" state: (1) the name of each person or entity involved: (2) the court, agency, association or exchange involved; (3) a summary of the allegations: (4) if applicable, the date of the conviction, judgment, decree, order or assurance; and (5) the penalty imposed, damages assessed and the nature thereof, terms and conditions of the judgment, decree, order of assurance. 2002 © American LegalNet, Inc. Each of the undersigned, constituting all the officers, directors, partners or principals of the franchise sales agent do hereby state and represent that all statements contained herein are true and correct and understands that any false statement shall constitute a violation of Article 33 of the General Business Law. Signature Name and Title (please type or print) Date ________________ _______________________________________ _______ ________________ _______________________________________ _______ ________________ ________________________________________ ______ ________________ _______________________________________ ______ ________________ _______________________________________ _____ 2002 © American LegalNet, Inc.