STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL ANDREW CUOMO ATTORNEY GENERAL Franchise registration forms, statutes, regulations and guidelines can be downloaded from www.oag.state.ny.us FORM E - 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. Birthday; 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? YES NO B. Had during the ten-year period immediately before the offering circular date: (1) been convicted of a felony or pleaded nolo contendere to a felony charge or been held liable in a civil American LegalNet, Inc. www.FormsWorkflow.com action by final judgment if the felony or civil action involved a violation or 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 ______________________________ (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) the name of the 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, terms and conditions of the judgment, decree, or order or assurance. American LegalNet, Inc. www.FormsWorkflow.com