An application for registration of a material modification of franchises pursuant to Section 31125 of the Code shall, in addition to the facing page of the Uniform Franchise Registration Application, as defined in Section 310.111(b), continue on the following form:

EXHIBIT 1

Attach a copy of the item(s) of the Uniform Franchise Offering Circular, complying with Section 310.114.1 of these rules, if the information is changed. State the existing arrangement and the new arrangement with respect to the item(s). The cover of the Offering Circular shall state: “The changes set forth herein are voluntary. If a franchisee does not receive the attached disclosure at least five business days prior to the execution of a binding agreement, the franchisee may, by written notice, mailed or delivered to the franchisor or (specify agent of the franchisor), within five business days following the execution of the agreement rescind the agreement to the modifications.”

Describe the proposed modifications, including:

EXHIBIT 2

Attach a copy of the franchise contract or document which embodies the modification(s).

EXHIBIT 3

State the number of franchises presently operating, the number of such franchises presently operating in California and the number of franchises proposed to be modified and the number of franchises proposed to be modified in California.

EXHIBIT 4

Attach the Consent to Service of Process if required by Section 31155 of the California Corporations Code, if one has not previously been filed.

EXHIBIT 5

The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.

I certify or declare under penalty of perjury that I have read this application and the exhibits thereto and know the contents thereof, and that the statements therein are true and correct.

Executed at _________________________, California, on the date of ____________________, __________

If executed at any place within or without this state: I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at ______________________________, on the date of _______________, _____