Form 3401 (Revised 03/15) Submit to: Secretary of State Registrations Unit P.O. Box 13550 Austin, TX 78711-3550 512 475-0775 FAX: 512 475-2815 Filing Fee: $200.00 PLEASE CHECK: This space reserved for office use. Telephone Solicitation Registration Statement _____ NEW _____ RENEWAL Please print or type. Use additional sheets of paper if necessary. Answer all questions. Please indicate if question is not applicable. 1.) Seller's Name: ____________________________________________________________________________________ 2.) Name under which seller intends doing business if different from above: ____________________________________________________________________________________ 3.) The seller's business form (i.e. individual, sole proprietorship, firm, association, corporation, partnership, joint venture, or other business entity) and place of organization is: ____________________________________________________________________________________ 4.) If the seller is a corporation, attach a copy of it's articles of incorporation and bylaws; if a partnership, a copy of the partnership agreement. If a limited liability company, its articles of organization and regulations. 5.) If seller is operating under an assumed business name, the location where the assumed name has been registered is: _____________________________________________________________________________________ 6.) Attach a list of the name of each parent and affiliated organization of seller that will engage in business transactions with purchasers relating to sales solicited by the seller or accepts responsibility for statements made by, or acts of, the seller relating to sales solicited by the seller. 7.) For each organization listed in #6 above, give the type of business form and place of organization and provide: A. A copy of the articles of incorporation and bylaws, if a corporation; B. A copy of the partnership agreement, if a partnership; C. A copy of the articles of organization and regulations, if a limited liability company; and 1 American LegalNet, Inc. www.FormsWorkFlow.com D. If operating under an assumed business name, the location where the assumed name has been registered. 8.) Attach a list with the complete street address of each location of the seller, designating the principal location from which the seller will be conducting business. 9.) If the principal business location is not in this state, designate below the main location in this state. ____________________________________________________________________________________ ____________________________________________________________________________________ 10.) List below each telephone number to be used by the seller and the address where each telephone is located. _____________________________________________________________________________________ _____________________________________________________________________________________ 11.) Attach a list containing: A. The name and title of each of the seller's officers, directors, trustees, general and limited partners, sole proprietor, and owners, as applicable, and the name of each of those persons who have management responsibilities in connection with the seller's business activities. B. The complete address of the principal residence, the date of birth, the number and state of issuance of the driver's license of each person whose name is disclosed under (A.) above. 12.) Attach a list with the name and principal residence address of each person in charge at each location from which the seller does business in this state, and the business location at which each of these persons is or will be in charge. 13.) With respect to #11 & #12 above, and pursuant to Section 302.152, Tex. Bus. & Com. Code, identify each person: A. Who has been convicted of or pleaded nolo contendere to a felony or misdemeanor involving an alleged violation of Chapter 302, Tex. Bus. & Com. Code, or fraud, theft, embezzlement, fraudulent conversion, or misappropriation of property; B. Against whom a final judgment or order in a civil or administrative action has been entered, including a stipulated judgment or order, in which the complaint or petition alleged acts constituting a violation of Chapter 302, Tex. Bus. & Com. Code, fraud, theft, embezzlement, fraudulent conversion, or misappropriation of property, the use of untrue or misleading representations in an attempt to sell or dispose of real or personal property, or the use of unfair, unlawful, or deceptive business practices; C. Who is subject to an injunction or restrictive court order relating to business activity as the result of an action brought by a federal, state, or local public agency, including an action affecting any vocational license; or 2 American LegalNet, Inc. www.FormsWorkFlow.com D. Who has, during the previous seven tax years, filed a bankruptcy, been adjudged a bankrupt, been reorganized due to insolvency, or has been a principal, director, officer, trustee, general or limited partner, or had management responsibilities of a corporation, partnership, joint venture, or other business entity that has filed in bankruptcy, been adjudged a bankrupt, or been reorganized due to insolvency while the person held that position or within one year after the date on which the person last held that position. Under (A), (B), and/or (C), identify the court or administrative agency rendering the conviction, judgment, or order, the docket number of the matter, the date of conviction, judgment, or order, and the name of the governmental agency, if any, that brought the action resulting in the conviction, judgment, or order. Under (D), include the name and location of the person filing in bankruptcy, adjudged a bankrupt, or reorganized due to insolvency, and include the date of the filing, judgment, or reorganization order, the court having jurisdiction, and the docket number of the matter. 14.) Attach a list containing the name and principal residence address of each salesperson who solicits on behalf of the seller or a copy of the "Employer's Quarterly Report" for employee wages the seller files with the Texas Workforce Commission. Include the name the salesperson uses while soliciting. 15.) The name and address of the seller's agent in this state, other than the secretary of state, authorized to receive service of process is: _____________________________________________________________________________________ ________________________________________________________