Fill and Sign the 1010 Richards Street Form

FF 6/03© STP4020-1 Form 4.02Hawaii STATE OF HAWAII DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS Business Registration Division 1010 Richards Street Mailing Address: Post Office Box 40, Honolulu, Hawaii 96810 APPLICATION FOR (Check only one): FEE: [Applicable Fee Amount] ( )Registration of an offer or sale of franchises.( )Supplemental Report to Registration Statement.1.Name of Franchisor: Name under which Franchisor is doing or intends to do business:Name of any parent or affiliated company that will engage in business transactions with Franchisees: 2.Franchisor's principal business address: Name and address of Franchisor's agent in the State of Hawaii authorized to receive process: Director, Department of Commerce and Consumer AffairsBusiness Registration Division1010 Richards StreetPost Office Box 40Honolulu, Hawaii 968103.State the business form of the Franchisor, whether corporate, partnership, or otherwise. (If corporate, date of organization and State of Corporation):4. Exhibits required by the application are attached hereto and made a part hereof. Form 4.024020-2© STPFF 6/03 SUPPLEMENTAL INFORMATION 1.Disclose:A.The states in which this proposed registration application is effective.B.The states in which this proposed registration application is or will be shortly on file.C.The states that have refused to register this franchise offering.D.The states that have revoked or suspended the right to offer franchises.E.The states in which this proposed registration of these franchises has been withdrawn within the last five years, and the reasons for revocation or suspension.2.Source of Funds for Establishing New FranchisesDisclose franchisor’s total costs for performing its pre-opening obligations to provide goods or services in connection with establishing each franchise, including real estate, improvements, equipment, inventory, training and other items stated in the offering. State separately the sources of all required funds. Form 4.02 FF 6/03© STP4020-3 CERTIFICATION I certify under penalty of law that I have read and know the contents of this application and the documents attached as exhibits and incorporated by reference and that the statements in all these documents are true and correct. Executed at , , 20 .[FRANCHISOR]By: _______________________________________ [Signing Officer] Title: (SEAL)STATE/PROVINCE OF COUNTY/CITY OF Personally appeared before me this day of , 20, the above-named [Signing Officer], to me known to be the person who executed the foregoing application as [title] of the above- named applicant and, being first duly sworn, stated upon oath that said application, and all exhibits submitted herewith, are true and correct. (Notary's Seal) __________________________________________ (Notary) Form 4.024020-4© STPFF 6/03 CORPORATE ACKNOWLEDGMENT STATE/PROVINCE OF ) ) ss COUNTY/CITY OF ) On this day of , 20 , before me (Name of Notary) the undersigned officer, personally appeared [Signing Officer] and , known personally to me to be the [title] and [title], respectively, of the above-named corporation, and that they, as such officers, being authorized to do so, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by themselves as such officers. IN WITNESS WHEREOF I have hereunto set my hand and official seal. ______________________ (Notary Public) (NOTARIAL SEAL) My commission expires: Form 4.02 FF 6/03© STP4020-5 UNIFORM CONSENT TO SERVICE OF PROCESS [Franchisor], a corporation organized under the laws of the State of , irrevocably appoints the Director, Department of Commerce and Consumer Affairs of the State of Hawaii and the successors in office, its attorney in the State of Hawaii for service of notice, process or pleading in an action or proceeding against it arising out of or in connection with the sale of franchises, or a violation of the franchise laws of Hawaii, and consents that an action or proceeding against it may be commenced in a court of competent jurisdiction and proper venue within Hawaii by service of process upon this officer with the same effect as if the undersigned was organized or created under the laws of Hawaii. It is requested that a copy of any notice, process or pleading served this consent be mailed to: [Franchisor’s Principal Contact or Franchisor’s Attorney] Dated: , 20.[FRANCHISOR]By:_____________________________ [Signing Officer] Title: (SEAL) By: _____________________________ Title: Form 4.024020-6© STPFF 6/03 STATE OF HAWAII Sales Agent Disclosure Form I.List the persons who will offer or sell franchises in this state. For each person state: 1(a)(name)(b)(business address)() -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years2(a)(name)(b)(business address)( ) -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years Form 4.02 FF 6/03© STP4020-73(a)(name)(b)(business address)() -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years4(a)(name)(b)(business address)( ) -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years Form 4.024020-8© STPFF 6/035(a)(name)(b)(business address)() -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years6(a)(name)(b)(business address)( ) -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years Form 4.02 FF 6/03© STP4020-97(a)(name)(b)(business address)() -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years8(a)(name)(b)(business address)( ) -(business phone)(c)(home address)( ) -(home phone)(d)[Franchisor](present employer)(e)(title)(f)(social security number)(g)(birthdate)(h)Employment during the past five years II. State whether any person identified in I. above:(A) Has any administrative, civil or criminal action pending alleging a violation of franchise or securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations?YES ( ) NO ( X ) Form 4.024020-10© STPFF 6/03(B)Had during the ten-year period immediately before the offering circular date:(1) been convicted of a felony or pleaded nolo contendere to a felony charge or been held liable in a civil action by final judgment if the felony or civil action involved a violation of franchise or securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or comparable violations of law?YES ( ) NO ( X )(2) entered into or been named in a consent judgment, decree, order or assurance under federal or state franchise, securities, anti-trust, monopoly, trade practice, or trade regulation law?YES ( ) NO ( X )(3) been subject to any order or national securities association or national securities exchange as defined in the Securities and Exchange Act of 1934 suspending or expelling the person from membership in the association or exchange?YES ( ) NO ( X ) Form 4.02 FF 6/03© STP4020-11 CONSENT OF INDEPENDENT ACCOUNTANTS We hereby consent to the use in the Franchise Offering Circular for the State of Hawaii of our reports dated , relating to the Audited Financial Statements of [Franchisor], as of , which appear in such Franchise Offering Circular. Certified Public AccountantDated: , 20.