Name, Title/Position (if known), Address, Telephone Number and Email/Internet address (if known) of person you dealt with:
TRANSACTION INFORMATION:
Describe how you contacted or were contacted by the Business Broker:
Did you sign a contract for the Business Broker’s services?
❏ Yes (indicate date you signed the contract):
❏ No
Did you have the contract reviewed by an attorney before signing?
❏ Yes (indicate name and address of attorney):
❏ No
Did the Business Broker provide you a written description of the services to be performed, the circumstances under which the Business
Broker would be entitled to keep or receive a fee, and the business history of the business broker?
❏ Yes (indicate when this was provided to you):
❏ No
MISCELLANEOUS:
Have you filed an inquiry or complaint with the Business Broker, the Better Business Bureau or any other person or governmental agency?
❏ Yes
❏ No
If yes, indicate Name, Address and Telephone Number of Person or Agency, and Date:
What, if any, action has been taken?
Have you obtained private legal counsel?
❏ Yes
❏ No
If yes, indicate Name, Business Address and Telephone Number of Attorney:
ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all canceled checks or other evidences of
payment of the Business Broker’s fee.)
Are you willing to be interviewed by a Securities Department investigator?
❏ Yes
❏ No
Are you willing to testify if formal proceedings are commenced?
❏ Yes
❏ No
DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY
DISCUSSION BETWEEN YOU AND THE BUSINESS BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS:
Signature of Borrower Date
