Franchise Seller Disclosure Form

Name

First NameLast Name

Your FCC E-mail

Company Name that is Brokering Franchises (Or Your Name if not applicable - Not FCC!)

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

What is your complete 5 year Employment History up until the present?

Has an administrative, criminal or material civil action pending against you alleging a violation of franchise, antitrust or securities law, or alleging fraud, unfair or deceptive practices, or any comparable allegations occurred?

Had you during a 10-year period immediately before this disclosure document’s issuance date been convicted of or pleaded no contest to a felony charge; or been held liable in a civil action involving an alleged violation of a franchise antitrust or securities law, or allegations of fraud, unfair or deceptive practices, or comparable allegations?

Are you subject to a currently effective injunction 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.

If you answered “yes”, to one or more of the questions above please provide for all relevant cases: Names of the parties, Forum, nature and current status of the pending action and Case or proceeding identification number.

E Signature

Current Date