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|  | | Fields marked with * are
mandatory. |
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| Personal Information |
| *First Name: |
| *Last Name: |
|
| *Email: | |
| Gender
: | Male
Female | US
Citizen : | Yes
No |
| Present
Address: | | Social
Security #: | |
| Work
Phone: | |
| *City: | | *State: | |
| * Zip Code: | | *Country: | |
| How
long at this address? (Yrs): | | Previous
Address: | |
| City: | | State: | |
| Zip
Code: | | Country: | |
| Birth
Date: |
|
| Home
Ownership : |
Own
Renting | Marital Status : |
Single
Married |
| Spouse
Name : |
| Spouse
Social Security #: |
|
| Spouse
US Citizen : |
Yes
No | Spouse
Birth Date: |
|
| Assets & Liabilities |
| 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 ($): |
|
| Total Contingent Liabilities |
| Loan
Co-signature: |
| Legal
Judgment: |
|
| Income
Taxes: |
| Other
Special Debt: |
|
| Total: |
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| Specific Data |
| When
would you be ready to invest in your franchise if you were
approved?: | | What
skills/experience do you have that will help you be successful in
this business?: | |
| Why do
you think this franchise will enable you to reach your personal
goals?: | | Who will
be responsible for the daily operation of your store?: | |
| Amount
of cash available for investment?: |
|
| Have
you been approved for financing?: |
Yes
No | Amount
Approved ($): |
|
| Would
this business be your sole income source?: |
Yes
No |
| Do you
have any contingent liabilities for guarantees, endorsements, leases
etc ?: |
Yes
No | Are
you now, or have you ever been party to any lawsuit - either as
defendant or plaintiff ?: |
Yes
No |
| Have
you ever been convicted of any offense (including misdemeanors for
which you have fined $ 200 or more) ?: |
Yes
No |
| Have
you ever been convicted of a felony?: |
Yes
No | If so,
explain: | |
| Have
you ever filed for bankruptcy?: |
Yes
No |
| Date
Filed: |
| Date
Discharged: |
|
| 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: | |
| |
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