Fill and Sign the 20 F 1 Tv51883820fhtm Form 20 F United

FF 10/96© STP4162-1Form 4.16[2]—New York STATE OF NEW YORK DEPARTMENT OF LAW BUREAU OF INVESTOR PROTECTION AND SECURITIES FRANCHISE SALES AGENT STATEMENT 1.Firm Name: ______________________________________________________________________2.Principal Office: __________________________________________________________________3. Give the following information with regard to each corporate officer, director, partner or other principal of the franchise sales agent (use additional pages as riders to this form, where necessary):A. Name: ___________________________________________________________________________ B.Business address and telephone numberC.Home address and telephone number ___________________________________________________________________________ D.Present Title _________________________________________________________________E.Social Security Number ________________________________________________________F. Birth date ___________________________________________________________________G. Employment or occupation during the past 5 years. For each such employment state the name of the employer, position held and beginning and termination dates for each such employment.4. State whether any person identified in 1 or 3 above  Some states will allow their forms to be input on the applicant's word processing system rather than actually typing the information on a hard copy of the form (i.e., Illinois and New York broker applications). Form 4.16[2]4162-2© STPFF 10/96A.Has any administrative, civil or criminal action pending against him alleging a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations? Yes. No . Give details in a rider attached to this statement. B.Has(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 such felony or civil action involved a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable violations of law. Yes . No . Give details in a rider attached to this statement. (2) entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, securities, antitrust, monopoly, trade practice, or trade regulation law? Yes . No . (3) been subject to any order of any national securities association or national securities exchange (as defined in the Securities and Exchange Act of 1934) suspending or expelling such person from membership in such association or exchange. Yes No .C.With respect to each question above answered ‘Yes’ state:(1) the name of each person or entity involved;(2)the court, agency, association or exchange involved;(3) a summary of the allegations;(4)if applicable, the date of the conviction, judgment, decree, order or assurance; and(5) the penalty imposed, damages assessed and the nature thereof, terms and conditions of the judgment, decree, order or assurance.Each of the undersigned, constituting all of the officers, directors, partners or principals of the franchise sales agent do hereby state and represent that all statements contained herein are true and correct and understand that any false statement shall constitute a violation of Article 33 of the General Business Law. SignatureName and Title (please type or print) Date Form 4.16[2] FF 10/96© STP4162-3 STATE OF NEW YORK DEPARTMENT OF LAW BUREAU OF INVESTOR PROTECTION AND SECURITIES SUPPLEMENTAL FRANCHISE SALES AGENT STATEMENT Firm Name ___________________________________________________________________________Principal Office _______________________________________________________________________A Franchise Sales Agent shall, not later than 20 days after occurrence, complete this statement to report:1. Change of corporate officers, directors, partners or other principals of the franchise sales agent.A.Employed: DateNameAddress B.Terminated: DateNameAddress 2.Whether any of the persons listed in 1-A aboveA.Has any administrative, civil or criminal action pending against (him) (her) alleging a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable allegations.B. Has(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 such felony or civil action involved a violation of any franchise law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practices, misappropriation of property or any comparable violations of law.(2) entered into or been named in any consent judgment, decree, order or assurance under any federal or state franchise, securities, anti-trust, monopoly, trade practice, or trade regulation law.(3)been subject to an order of any national securities association or national securities exchange (as defined in the Securities and Exchange Act of 1934) suspending or expelling such person from membership in such association or exchange. Form 4.16[2]4162-4© STPFF 10/96C.With respect to each of the above state:(1) the name of each person involved;(2)the court, agency, association or exchange involved;(3) a summary of the allegations;(4)if applicable, the date of the conviction, judgment, decree, order or assurance; and(5) the penalty imposed, damages assessed and the nature thereof, terms and conditions of the judgment, decree, order or assessment.Each of the undersigned, constituting all of the officers directors, partners or principals of the franchise sales agent do hereby state and represent that all statements contained herein are true and correct and understands that any false statement shall constitute a violation of Article 33 of the General Business Law. SignatureName and Title (please type or print) Date