Franchise Seller Disclosure Form (Page 2 of 3) in pdf

Franchise Seller Disclosure Form 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 Ayes@, please provide:

Name of the person:

Public agency or court:

Case or proceeding identification number:

Franchisor:

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

________________

(NOTARIAL SEAL)

My Commission Expires: ________________

Franchise Seller Disclosure Form Page 2