Fillable Consumer Statement Business Opportunity Illinois Secretary of State (Illinois Secretary of State)

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Consumer Statement Business Opportunity Illinois Secretary of State (Illinois Secretary of State)

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The Consumer Statement Business Opportunity Illinois Secretary of State (Illinois Secretary of State) form is 3 pages long and contains:

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  • 12 check-boxes
  • 84 other fields

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Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
S
pringfield, IL 62701 • 217-782-2256
69 W. Washington St., Ste. 1220
Chicago, IL 60602 • 312-793-3384
800-628-7937
Business Opportunity
Consumer Statement
CONSUMER INFORMATION:
Name: Age:
Address:
City: State: ZIP:
Home Telephone Number: Work Telephone Number:
Please indicate the most convenient day to be contacted:
❏ Monday
❏ Tuesday
❏ Wednesday
❏ Thursday
❏ Friday
Please indicate the most convenient time and place to be contacted:
❏ Work (indicate time):
❏ Home (indicate time):
COMPANY INFORMATION:
Name, Title (if known), Address and Telephone Number of each person who offered or sold you the Business Opportunity:
CONTACT:
Was the Business Opportunity offered or sold at a fair or trade show?
❏ Yes (indicate location of fair or show and date):
❏ No
Did you respond to an advertisement based on a televised infomercial or radio broadcast?
❏ Yes (indicate station and date):
❏ No
Did you respond to a newspaper or magazine advertisement?
❏ Yes (indicate publication and approximate date):
❏ No
Did the company or its representative contact you by telephone?
❏ Yes (indicate name of person and approximate date):
❏ No
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 307.1
By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Business Opportunities Company
and/or Seller. The information received will enable the Securities Department to conduct a more accurate inquiry.
Name Title Address Telephone Number
Name Title Address Telephone Number
Name Title Address Telephone Number
Name Title Address Telephone Number
Location and Date
Station and Date
Publication and Date
Publication and Date
Print
Reset
Save
Did you learn about the Business Opportunity via the Internet?
❏ Yes (indicate Internet address of company, approximate date — include a copy of the page if available):
❏ No
If contact by other means, please indicate type of contact:
Did you receive a written contact or other written materials?
❏ Yes
❏ No
Did you receive a disclosure document before purchasing the Business Opportunity?
❏ Yes
❏ No
Describe the Business Opportunity:
AMOUNT AND FORM OF PAYMENT:
Amount of Initial Payment: Date Payment Made:
Payment made by:
❏ Cash:
❏ Credit Card:
❏ Promissory Note/or other Obligation to Pay:
❏ Check (indicate amount and check number):
❏ Other form of payment (please specify):
After the initial payment, were you required to make any additional payments?
❏ Yes (indicate amount, number and frequency of payments):
❏ No
Were these additional payments or fees disclosed in the original contact or agreement?
❏ Yes
❏ No
Internet Address and Date
MISCELLANEOUS QUESTIONS:
Have you filed an inquiry or complaint with the company, the Better Business Bureau or any other person or governmental agency?
❏ Yes
❏ No
I
f 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 PAPERS REGARDING THE BUSINESS OPPORTUNITY THAT WAS EITHER OFFERED OR SOLD TO YOU. (Include the
front and back of all canceled checks.)
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 THE REASON FOR FILING THIS STATEMENT — IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS:
Signature of Consumer Date
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Consumer Statement Business Opportunity Illinois Secretary of State (Illinois Secretary of State)

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Completed 28 August 2020

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