Section 200

Section 200.APPENDIX A Franchise Registration Forms

Section 200.ILLUSTRATION G Certification Page

I certify under penalty of law that I have read this notification and the exhibits attached hereto and incorporated herein by reference, and know the contents thereof and that the statements therein are true and correct.

Executed at	,	Illinois	,	.
(SEAL)

		(Signature(s) of Franchisor, Subfranchisor or Broker)
		By
		Title

STATE OF	)	SS
	)
COUNTY OF	)

Personally appeared before me this

day of,

the above-named

(and)

to me known to be the

person(s) who executed the foregoing notification (as

and

respectively, of the above-named applicant) and (each) being

first duly sworn, stated upon oath that said notification, and all exhibits submitted herewith, are true and correct.

(Notarial Seal)

Notary

(Source: Amended at 23 Ill. Reg. 11561, effective September 7, 1999)