Licensing and Regulation PO Box 43098 Olympia, WA 98504-3098 Phone: 360-664-1600 FAX: 360-753-2710 www.lcb.wa.gov License Number Trade Name UBI Number Franchise Affidavit (RCW 66.24.010) This affidavit is in lieu of providing a copy of the franchise agreement to the Washington State Liquor and Cannabis Board for the below premises: Trade Name: UBI Number: Address of real/personal property: Name of franchisor: Name of franchisee: Date franchise begins: Number of times franchise can be renewed: Fees: Franchise: Other fees: Premises use: Can franchise be assigned? With or without franchisor's written consent? $ $ Royalty: $ Date franchise expires: Term of each renewal: Training: $ Liquor License No. Print Name of Franchisor Signature of Franchisor Date I declare under penalty of perjury that all information provided on this form is true and complete to the best of my knowledge. I understand that unlawful, misleading or incomplete answers, whether through misrepresentation, concealment, inadvertence, or mistake, are cause for denial of a license or revocation of any liquor licenses currently held. Click Here to Select Your Title Title Date Print Name of Applicant Signature of Applicant LIQ 820 7/15 American LegalNet, Inc. www.FormsWorkFlow.com