Fill and Sign the Virginia Uniform Franchise Registration Application

FF 6/03© STP4130-1 Form 4.13Virginia VIRGINIA UNIFORM FRANCHISE REGISTRATION APPLICATION FILE NO. (Insert file number of previous filings of Applicant, if any) FEE: [Applicable Fee Amount] (Enclosed by application is initially filed) APPLICATION FOR (Check only one): REGISTRATION OF AN OFFER AND SALE OF FRANCHISESREGISTRATION RENEWAL STATEMENT OR ANNUAL REPORT AMENDMENT NUMBERTO APPLICATIONPOST-EFFECTIVEFILED UNDER SECTIONPRE-EFFECTIVEDATED1.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 Virginia authorized to receive process. Clerk of the State Corporation Commission P.O. Box 1197 Richmond, Virginia 232193.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 4.134130-2© 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suspended the right to offer franchises.E.The states in which this proposed registration of these franchises has been withdrawn within the last five years, and the reasons for revocation or suspension.2.Source of Funds for Establishing New FranchisesDisclose franchisor’s total costs for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 4.13 FF 6/03© STP4130-3 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 4.134130-4© 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 4.13 FF 6/03© STP4130-5 UNIFORM CONSENT TO SERVICE OF PROCESS [Franchisor], a corporation organized under the laws of the State of , irrevocably appoints the Clerk of the State Corporation Commission of Virginia and the successors in office, its attorney in the State of Virginia 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 Virginia, and consents that an action or proceeding against it may be commenced in a court of competent jurisdiction and proper venue within Virginia by service of process upon this officer with the same effect as if the undersigned was organized or created under the laws of Virginia. It is requested 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 4.134130-6© STPFF 6/03 CONSENT OF INDEPENDENT ACCOUNTANTS We hereby consent to the use in the Franchise Offering Circular for the State of Virginia 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.