Franchise Team Form Name of Franchise* Your Name* First Last Your Business Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Business Phone Number* Are you completing this as (check all that apply)* a director or principal of the Franchisor an officer or manager of the Franchisor a franchise trainer a salesperson employed by the Franchisor a franchise broker of the Franchisor a salesperson employed by the franchise broker other If 'other' then please list* Will you engage in franchise sales for the Franchisor?* Yes No Complete the following employment history chart for the prior five-year period (beginning with the job you held six years ago). For each employment (including current employment by franchisor), state the name of the employer, position held, location of employment (city/state), and beginning and ending dates (month/year). If unemployed, you must disclose that fact; the ENTIRE five-year period must be accounted for.Employment history chart*Employer Name (Legal Entity Name)Position TitleLocation Of Employment (City & State)Beginning And Ending Dates (Month & Year) Please answer the following litigation and bankruptcy questions.1. Do you have pending against you an administrative, civil, or criminal action alleging a violation of franchise, antitrust or securities law, fraud, unfair or deceptive practices, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practice, misappropriation of property, or any comparable allegations?* Yes No 2. Were you a party to any civil action involving a “franchise relationship” in the last fiscal year?* Yes No 3. Within the prior ten-year period, have you been convicted of or pleaded nolo contendere to a felony charge or been “held liable” in a civil action alleging violation of franchise, antitrust or securities law, fraud, unfair or deceptive practices, embezzlement, fraudulent conversion, restraint of trade, unfair or deceptive practice, misappropriation of property, or any comparable allegations?*[Note: “Held liable” means that, as a result of claims or counterclaims, you must pay money or other consideration, must reduce an indebtedness by the amount of an award, cannot enforce your rights, or must take action adverse to your interests.] Yes No 4. Are you subject to a currently effective injunctive or restrictive order or decree resulting from a pending or concluded action brought by a public agency and relating to the franchise or to a Federal, State, or Canadian franchise, securities, antitrust, trade regulation, or trade practice law?* Yes No 5. Are you subject to a currently effective order of any national securities association or national securities exchange suspending or expelling you from membership in such association or exchange?* Yes No 6. Within the prior 15-year period, have you filed as debtor (or had filed against you) a petition to start an action under the U.S. Bankruptcy Code or a foreign bankruptcy law?* Yes No 7. Within the prior 15-year period, have you obtained a discharge of your debts under the U.S. Bankruptcy Code?* Yes No 8. Within the prior 15-year period, have you been a principal officer of a company or a general partner in a partnership that either filed as a debtor (or had filed against it) a petition to start an action under the U.S. Bankruptcy Code or that obtained a discharge of its debts under the U.S. Bankruptcy Code during or within one year after you held this position in the company or partnership (check “yes” if you were an officer or partner when the company experienced the bankruptcy event or if the company experienced the bankruptcy event within one year after you ceased to be an officer or general partner)?* Yes No CommentsThis field is for validation purposes and should be left unchanged. Δ
