Form I - Franchise Broker Registration (Page 2 of 4) in pdf

Form I - Franchise Broker Registration Page 2

Is subject to a currently effective injunction or restrictive order or decree

resulting from a pending or concluded action brought by a public agency

and relating to the franchise, or to a Federal, State or Canadian franchise,

securities, antitrust, trade regulation or trade practice law.

Yes ____

No ____

If you answered “yes”, please provide:

Name of the person:

Public agency or court:

Case or proceeding identification number:

4. Franchise Broker designates the New York Secretary of State as agent to receive

process in its Consent to Service of Process, a copy of which is enclosed.

Franchise Broker:_______________

By:___________________________

Name:_________________________

Title:__________________________

STATE OF____________ )

)

COUNTY OF __________)

Personally appeared before me this ___ day of _____, 20__, the above-named

____________________, to me known to be the person who executed the foregoing application

(as _____________________ of the above name applicant) and, after being administered an

oath and duly sworn, swore upon oath that said application, and all exhibits submitted herewith,

are true and correct.

Notary Public

________________

My Commission Expires: ________________

Form I - Franchise Broker Registration Page 2