Rhode Island Uniform Franchise Registration Application

RHODE ISLAND UNIFORM FRANCHISE REGISTRATION APPLICATION

File No.

Fee: (Enclosed when application is initially filed)

APPLICATION FOR (Check only one):

Registration of an offer and 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 Rhode Island authorized to receive process.

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.

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E. The states in which this proposed registration of these franchises has been withdrawn within the last five years, and the reasons for revocation or suspension.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, improvements, equipment, inventory, training and other items stated in the offering. State separately the sources of all required funds.

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 , ,

[FRANCHISOR]

(SEAL)

STATE/PROVINCE OF

COUNTY/CITY OF

Personally appeared before me this day of , the above-named to me known to be the person who executed the foregoing application as 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.

CORPORATE ACKNOWLEDGMENT

STATE/PROVINCE OF )

COUNTY/CITY OF ) ss

On this day of , 20 , before me the undersigned officer, personally appeared and , known personally to me to be the and , respectively, of the above-named corporation...

My commission expires:

UNIFORM CONSENT TO SERVICE OF PROCESS

, a corporation organized under the laws of the State of , irrevocably appoints the Director of Business Regulation, State of Rhode Island and the successors in office, its attorney in the State of Rhode Island for service of notice, process or pleading...

It is requested that copy of any notice, process or pleading served this consent be mailed to:

Dated:

[FRANCHISOR]

STATE OF RHODE ISLAND
Sales Agent Disclosure Form

I. List the persons who will offer or sell franchises in this state. For each person state:

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

(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

(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

(3) been subject to any order of a 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

CONSENT OF INDEPENDENT ACCOUNTANTS

We hereby consent to the use in the Franchise Offering Circular for the State of Rhode Island of our reports dated , relating to the Audited Financial Statements of , as of , which appear in such Franchise Offering Circular.

Dated: