Fields marked with * are mandatory.

Personal Information

*First Name: *Last Name: Date:
*Email: Gender: US Citizen:
Male Female Yes No
Present Address: Social Security #: Home Phone:
Home Phone Extension: Work Phone: Work Phone Extension:
*City: *Country: *State / Province:
*Zip / Postal Code: How long at this address? (Yrs): Previous Address:
City: Country: State / Province:
Zip / Postal Code: Birth Date: Best Time To Call:
Home Ownership: Marital Status: Spouse Name:
Own Renting Single Married
Spouse Social Security #: Spouse US Citizen: Spouse Birth Date:
Yes No

Assets & Liabilities



Cash on Hand & in Banks ($): Mortgages ($):
Marketable Securities ($): Accounts Payable ($):
Accounts / Notes Receivable ($): Notes Payable ($):
Retirement Plans ($): Loans on Life Insurance ($):
Real Estate ($): Credit Cards (Total Balance) ($):
Personal Property ($): Unpaid Taxes ($):
Business Holdings ($):    
Life Insurance (CSV) ($):    
Other Assets ($): Other Liabilities ($):
Description: Description:

Total Assets:

Total Liabilities:

Total Net Worth:


Real Estate Owned

Real Estate 1

Address: Date Purchased: Original Cost:
Present Value: Mortgage Balance:

Real Estate 2

Address: Date Purchased: Original Cost:
Present Value: Mortgage Balance:

Real Estate 3

Address: Date Purchased: Original Cost:
Present Value: Mortgage Balance:

Annual Sources of Income

Salary ($): Investment ($): Real Estate Income ($):
Other ($): Description: Total ($):

Total Contingent Liabilities

Loan Co-signature: Legal Judgment: Income Taxes:
Other Special Debt: Total:

Specific Data

When would you be ready to invest in your franchise if you were approved?: What skills/experience do you have that will help you be successful in this business?: Why do you think this franchise will enable you to reach your personal goals?:
Who will be responsible for the daily operation of your store?: Amount of cash available for investment?: Have you been approved for financing?:
Yes No
Amount Approved ($): Would this business be your sole income source?: Do you have any contingent liabilities for guarantees, endorsements, leases etc ?:
Yes No Yes No
Are you now, or have you ever been party to any lawsuit - either as defendant or plaintiff ?: Have you ever been convicted of any offense (including misdemeanors for which you have fined $ 200 or more) ?:
Yes No Yes No
Have you ever been convicted of a felony?: If so, explain:
Yes No
Have you ever filed for bankruptcy?: Date Filed: Date Discharged:
Yes No

Area / Location Preferences

Preference 1: Preference 2: Preference 3:

Please list the three main questions you have about this business opportunity

Question 1: Question 2: Question 3: