Application Form

Birth Date*
MM
DD
YYYY
Your Age*
My ability to communicate with people from all walks of life is
- Above Average
- Average
- Below Average
Marital Status*
- Married
- Single
- Seperated
# Of Dependent(s)*
Age(s)
Spouse's Name
Spouse's Current Employment
Spouse's Birth Date
Spouse's Age*

Dependent(s)
If Other Than Above
Dependents Age(s)
If Other Than Above
Where did you hear about this business opportunity? (Please be specific)
What first attracted you to our company?
List 3 Character References Name/Address/Day Time Phone Number & Occupation
Character Reference #1
Character Reference #2
Character Reference #3
Employment during the last 5 years. List present or last job first.
Employer
Duties
Salary/Month
From - To
Employer
Duties
Salary/Month
From - To
How do you feel your business and/or job experience would help you run your own business?
FINANCIAL INFORMATION
Do you own your own Residence?*
- Yes
- No
How long have you owned it?
Name of Bank or Banks where you have accounts: Including stocks, bonds and their value. Bank Name / Address
Type of Account
Current Balance
$
List approximate value of stocks and bonds you own*
Your estimated total taxable income for the last 3 years
Year*
$*
Year*
$*
Year*
$*
List 3 Credit References
Name/Address
Type of Credit
Name/Address
Type of Credit
Name/Address
Type of Credit

Please fill in Social Security Number for each party involved
SSN
SSN
SSN
Do you plan to manage your Franchise personally?
- Yes
- No
Will you have a partner in this business?
- Yes
- No
How much will partner invest?
Will this partner be active in this business?
- Yes
- No
What driving radius are you willing to service from your home?*
- 10 or less miles
- 30 or less miles
- more than 30 miles
Who would primarily run the business?*
How flexible are your work hours?*
How much capital are you in a position to invest?*
State your estimated financial net worth*
Additional financial information (if any)

List 3 Character References Name/Address/Day Time Phone Number & Occupation