Fill and Sign the Iacigaingov Form

FF 6/03© STP 4040-1 Form 4.04 Indiana INDIANA UNIFORM FRANCHISE REGISTRATION APPLICATION FILE NO. (Insert file number of previous filings ofApplicant, if any) FEE: [Applicable Fee Amount] (Enclosed by application is initially filed) APPLICATION FOR (Check only one): REGISTRATION OF AN OFFER OR SALE OF FRANCHISES REGISTRATION RENEWAL STATEMENT OR ANNUAL REPORT AMENDMENT NUMBER TO APPLICATION POST-EFFECTIVE FILED UNDER SECTION PRE-EFFECTIVE DATED 1. Name of Franchisor. (If applicant is subfranchisor, the name of the subfranchisor.) Name under which the Franchisor is doing or intends to do business. 2. Franchisor's principal business address. Name and address of Franchisor's agent in the State of Indiana authorized to receive process. Indiana Secretary of State Room E-111 302 West Washington Street Indianapolis, Indiana 46204 3. Name, address and telephone number of subfranchisors, if any, for this state. 4. Name, address and telephone number of person to whom communications regarding this application should be directed. Form 4.04 4040-2© STP FF 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 E. The states in which this proposed registration of these franchises has been withdrawn within the last five years, and the reasons for revocation or suspension. 2.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 Franchises Disclose franchisor’s total costs for performing its pre-opening obligations to provide goods or services in connection with establishing each franchise, including real estate, i mprovements, equipment, inventory, training and other items stated in the offering. State separately t he sources of all required funds. Form 4.04 FF 6/03© STP 4040-3 CERTIFICATION I certify under penalty of law that I have read and know the contents of this applicati on and the documents attached as exhibits and incorporated by reference and that the statement s 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 4.04 4040-4© STP FF 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 t hey, 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 4.04 FF 6/03© STP 4040-5 UNIFORM CONSENT TO SERVICE OF PROCESS [Franchisor], a corporation organized under the laws of the State of , irrevocably appoints the Secretary of State of Indiana and the successors in office, it s attorney in the State of Indiana 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 Indiana, and consents that an action or proceeding against it may be commenced in a court of competent jurisdiction and proper venue within Indiana by service of process upon this officer with the same effect as if the undersigned was organized or created under the laws of Indiana. It is requeste d that copy of any notice, process or pleading served this consent be mailed to: [Addressee listed on First Application Page, Item #4] Dated: , 20 . [FRANCHISOR] By: _____________________________ [Signing Officer] Title: (SEAL) By: _____________________________ Title: Form 4.04 4040-6© STP FF 6/03 STATE OF INDIANA 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 years 2 (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 4.04 FF 6/03© STP 4040-7 3 (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 4 (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 4.04 4040-8© STP FF 6/03 5 (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 6 (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 4.04 FF 6/03© STP 4040-9 7 (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 8 (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 violat ion of franchise or securities law, fraud, embezzlement, fraudulent conversion, restraint of trade, unfair or dece ptive practices, misappropriation of property or any comparable allegations? YES ( ) NO ( X ) Form 4.04 4040-10© STP FF 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 dece ptive 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 4.04 FF 6/03© STP 4040-11 CONSENT OF INDEPENDENT ACCOUNTANTS We hereby consent to the use in the Franchise Offering Circular for the State of Indiana of our reports dated , relating to the Audited Financial Statements of [Franchisor], as of , which appear in such Franchise Offering Circular. Certified Public Accountant Dated: , 20 .