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Form 3001--General Information
(Health Spa Registration Application/Renewal)

The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information provided are not substitutes for the advice and services of an attorney.

Commentary Health Spas are governed by Chapter 702 of the Texas Occupations Code (the "Health Spa Act") and the secretary of state's administrative rules found in 1 Texas Administrative Code Chapter 102. Section 702.102 of the Health Spa Act sets forth the requirements for the issuance of a certificate of registration enabling a person to operate a health spa or offer for sale or sell a membership in a health spa. The Health Spa Act requires a separate registration for each health spa location. Certificates of registration are effective the date of issuance and are not transferrable. The certificate expires one year from the date of issuance and may be renewed. Any changes to the information provided on the application must be filed with the secretary of state within 90 days of the change. Form 3009 may be used to amend the total number of and amount paid for prepaid memberships. Instructions for Form · Preliminary Information: Select the appropriate box indicating whether this is a new application or an application for renewal. If it is a renewal, the registration number assigned by the secretary of state should be provided to facilitate processing of the document. · Applicant Information: The application for registration is filed by the applicant and must set forth the applicant's legal name, address, telephone number, and federal tax identification number. If the applicant is a corporation, limited liability company, or limited partnership, the legal name is the name registered with the secretary of state. These entities should also provide the registered office on file with the secretary of state. · Owner Information: The application must set forth the ownership information. ¾ If the applicant is a corporation or limited liability company, the application must provide the name and address of any person who directly or indirectly owns or controls 10% or more of the ownership interest of the entity. ¾ If the health spa is operated as a general partnership, the application must provide the name and address of all of the partners. ¾ If the health spa is operated as a limited partnership, the application must provide the name and address of each general partner. ¾ If the health spa is operated as a sole proprietorship, the application must provide the name and address of each person deemed to be an owner. ¾ The application must also provide the name and address of any person or entity holding any direct or indirect ownership of the health spa, if that person or entity exercises direct control of the health spa. If the health spa has more than three owners, use an additional sheet. A document on file with the secretary of state is a public record subject to public access and disclosure. When providing address information for owners, use a business or post office box address rather that a residence address if privacy concerns are an issue.

Form 3001

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· Litigation Disclosure: The application must disclose all litigation and/or complaints filed with a governmental authority relating to the failure to open or the closing of a health spa brought against the owners, officers, or directors of the health spa filing the registration statement that are currently pending or were completed within the past two years. If no such litigation or complaint is pending or was completed within the past two years, the application must contain a statement to that effect. · Health Spa Information: Provide the trade name or assumed name by which the applicant intends to do business and that is filed with the secretary of state or county clerk's office. This must match what is on the surety bond and the contracts. Provide the physical address of the health spa and select whether the health spa has other Texas locations. If the health spa has other registered locations in Texas and an identification number has been previously issued by the secretary of state, you should also provide the identification number. Provide the approximate square footage of the health spa. The application must include a description of the available or proposed facilities and services offered at the health spa location, e.g., aerobics, free weights, gymnasiums, running tracks, racquetball courts, martial arts equipment, exercise equipment, swimming pool, sauna, etc. Unless the health spa is exempt from the security requirement under subchapter E of the Health Spa Act, provide the total number of prepaid memberships at the health spa location and the total amount paid for all of the prepaid memberships. · Attachments: The following items must be included with the application: 1. Sample contract(s). A sample copy of each contract for use in connection with the sale of memberships to this health spa location. The contracts must conform to the requirements of subchapter G of the Health Spa Act. 2. Proof of security or exemption. Subchapter D of the Health Spa Act requires applicants to file security in the amount of not less than $20,000 or more than $50,000, sufficient to protect the health spa's total membership, unless the applicant is exempt by subchapter E. If the applicant is not exempt, provide proof of security in the form of a surety bond or certificate of deposit assigned to the secretary of state. If the applicant is exempt, attach Form 3006. Exemptions must be resubmitted every three years. 3. Filing fee of $100. · Execution: A person who is authorized to sign on behalf of the person or entity applying for a health spa registration certificate must sign and date the application before a notary public or other official who has authority to administer an oath. · Payment and Delivery Instructions: The filing fee for a health spa registration application or renewal is $100. Fees may be paid by personal checks, money orders, LegalEase debit cards or MasterCard, Visa, and Discover credit cards. Checks or money orders must be payable through a U.S. bank or financial institution and made payable to the secretary of state. Fees paid by credit card are subject to a statutorily authorized convenience fee of 2.7 percent of the total fees. The completed form, along with the filing fee, sample contracts, and proof of security, may be mailed to P.O. Box 13550, Austin, Texas 78711-3550; faxed to (512) 475-2815; or delivered to the James Earl Rudder Office Building, 1019 Brazos, Austin, Texas 78701. If documents are transmitted by fax, credit card information must accompany the transmission (Form 2101). The secretary of state will issue a certificate of registration upon filing of a completed application.
Revised 04/09

Form 3001

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Form #3001

Rev. 04/2009

This space reserved for office use

Submit to: SECRETARY OF STATE Statutory Documents Section P O Box 13550 Austin, TX 78711-3550 512-463-6906 512-475-2815 - Fax Filing Fee: $100

HEALTH SPA REGISTRATION APPLICATION / RENEWAL

Application for New Registration Application for Renewal of Registration

Registration Number:

Applicant Information
Applicant's Legal Name: Applicant's Address:
Street City State Zip

Phone: Mailing Address (if different from above):
Street

FEIN:

City

State

Zip

Registered office address on file with the secretary of state, if any:
Street City State Zip

Date applicant became owner and operator:

Owner Information
Complete for all owners. For corporations and limited liability companies, include each person who directly or indirectly owns or controls 10% or more of the ownership interest of the entity.

Name: Mailing Address:
Street City

FEIN:

State

Zip

Name: Mailing Address:
Street City

FEIN:

State

Zip

Name: Mailing Address:
Street City

FEIN:

State

Zip

LIST ANY OTHER OWNERS ON A SEPARATE SHEET
Form 3001 3

Litigation Disclosure
Complete one of the following:

A. Within the past two years, there has been no litigation and no complaint filed with a governmental authority relating to the failure to open or the closing of a health spa brought against the health spa owners, officers, or directors for which the registration statement is being filed. OR B. Litigation and/or complaint(s) filed with a governmental authority relating to the failure to open or the closing of a health spa brought against the owners, officers, or directors of the health spa filing the registration statement is currently pending or was completed within the past two years and is described below:

Health Spa Information
Trade or assumed name by which applicant intends to do business: Physical Address of Health Spa:
Street City State Zip

Does the health spa have other Texas locations? Approximate square footage of facility:

Yes

No Identification Number:

Describe the available or proposed facilities and services offered at this location:

Provide the number and total amount paid for prepaid memberships at this location unless exempt under §702.202

Number of prepaid memberships at this location: Total amount paid for all prepaid memberships: $

Attachments
The following items are included with this application: 1. A sample of each contract for use in connection with the sale of memberships to this location; 2. Proof of security or exemption as required by subchapter D of the Health Spa Act; and 3. $100 filing fee.

Execution
Date:
Signature of Applicant

State of County of

)

Printed or typed name of Applicant

) day of
Notary Public Signature

Sworn to and subscribed before me this (seal)

, 20

.

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Form 3001 4

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