Form Sfn 13401 - Trade Name Registration / Franchise Name Disclosure

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COMPLETE, PRINT, SIGN AND FAX OR MAIL

(If paying with credit card complete authorization at bottom of page 3)

FOR OFFICE USE ONLY

TRADE NAME REGISTRATION /

ID Number:

FRANCHISE NAME DISCLOSURE

WO Number:

SECRETARY OF STATE

SFN 13401 (07-2009)

Filed:

By:

Expiration Date:

SEE REVERSE SIDE FOR FEES, FILING AND MAILING INSTRUCTIONS

1. FILING FEE $25.00

TYPE OR PRINT LEGIBLY

Five Year Registration

For reference, see North Dakota Century Code, Chapter 47-25.

2. Is the name to be registered a franchise name licensed to a franchisee?

(A checkbox must be checked)

Yes

(If "No", proceed to number 3)

If "Yes", indicate whether this filing is a Trade Name Registration with ownership rights to the name or Disclosure Information:

Trade Name Registration with ownership rights to the name

Disclosure Information

If "Yes", provide the name, address, and phone number of the franchiser or other licensor of the franchise name:

Franchiser Name

Address

(Street, PO Box, City, State, Zip+4)

(Phone Number)

3. Trade Name to be registered or the Franchise Name licensed to franchisee:

4. Addresses of the places of business where the trade name or franchise name will be used or displayed:

Address

(Street, PO Box, City, State, Zip+4)

(Phone Number)

Address

(Street, PO Box, City, State, Zip+4)

(Phone Number)

5. The nature of the business transacted: (In detail)

6. Trade name is used and owned by or the franchise name is licensed to: (Select one)

Individual

Husband & Wife

Corporation incorporated in state of __________________________________

Limited Liability Company organized in state of __________________

Other - Define (See instructions)

7. Telephone number of owner or franchisee:

8. Toll-free telephone number:

9. The name of the individual(s), corporation, or the limited liability company, using the trade name or franchise name, their Federal ID/Social Security

Number, and the address of their principal place of business.

COMPLETE ADDRESS

FEDERAL ID/

NAME

SOCIAL

Street/RR

PO Box

City

State

Zip Code + 4

SECURITY

NUMBER

10. "I (We), the owner(s) or franchisee(s), say that I (we) have read the foregoing registration, know the contents thereof, and believe the statements made

to be true."

Signature:

Date:

Signature:

Date:

Daytime telephone number and

11. Name of person to contact about this form:

E-Mail Address:

extension, if any: