Request For Consideration Form

Date of Application (MM/DD/YYYY)*

Date

Name*

First NameMiddle NameLast Name

Best Email Address*

Telephone Number*

( ) 555-5555

Birth Date (MM/DD/YYYY)*

Date

Age

Current Address*

Current Address

Street Address Line 2

CityState

ZIP

How Long Lived There?*

Previous Address

Street Address Line 2

CityState

ZIP

How Long Lived There?

Marital Status

How Long?

Full Name of Spouse

Occupation of Spouse

Names and Ages of Dependent Children

Name

Age

Name

Age

Name

Age

Name

Age

Will the franchise be owned and operated by you or a group?*

Please explain fully

Amount of capital available for this business*

Describe fully

Territory for which application made*

Would you consider any other area?*

What area(s)?

THIS IS NOT A CONTRACT AND SUPPLYING OR COMPLETING THIS FORM INCURS NO OBLIGATION ON EITHER PARTY.

PLEASE LIST ALL EDUCATION YOU HAVE RECEIVED INCLUDING HIGH SCHOOL, COLLEGE, MILITARY OR SPECIAL TRAINING.

Name of School

Dates of Attendance (Start)

Date

Dates of Attendance (End)

Date

Major and Minor Fields

Location of School

Grade Average or Standing

Diploma or Degree

Date of Graduation (MM/DD/YYYY)

Date

Name of School

Dates of Attendance (Start)

Date

Dates of Attendance (End)

Date

Major and Minor Fields

Location of School

Grade Average or Standing

Diploma or Degree

Date of Graduation (MM/DD/YYYY)

Date

GIVE A COMPLETE RECORD OF YOUR EXPERIENCE, BEGINNING WITH YOUR PRESENT OR LAST POSITION. INCLUDE MILITARY SERVICE. INDICATE BY ASTERISK (*) THOSE EMPLOYERS YOU DO NOT WISH US TO CONTACT.

Have you been in business for yourself?

Name & Address of Employer

Position, Title & Duties

Dates of Employment

From (MM/YYYY) To (MM/YYYY)

Supervisor's Name & Title

Reason for Separation

Beginning Salary

Ending Salary

Name & Address of Employer

Position, Title & Duties

Dates of Employment

From (MM/YYYY) To (MM/YYYY)

Supervisor's Name & Title

Reason for Separation

Beginning Salary

Ending Salary

Name & Address of Employer

Position, Title & Duties

Dates of Employment

From (MM/YYYY) To (MM/YYYY)

Supervisor's Name & Title

Reason for Separation

Beginning Salary

Ending Salary

Ending salary

General Physical Condition

Date of Last Physical Exam

(MM/YYYY)

List Any Physical Impairments Or Chronic Illnesses Which May Preclude Certain Types Of Activities

Explain

What Year

EARNED (salary, commissions, fees, etc.)

$

Interest and Dividends Received

$

Rents Received

$

Other Income

$

Other Income 2

$

Other Income 3

$

TOTAL INCOME

$

PLEASE LIST THREE PROFESSIONAL & CHARACTER REFERENCES.

Name

Address

Telephone

( ) 555-5555

Name

Address

Telephone

( ) 555-5555

Name

Address

Telephone

( ) 555-5555

PLEASE LIST THREE CREDIT REFERENCES.

Name of Credit Reference

Address

Telephone

( ) 555-5555

Name

Address

Telephone

( ) 555-5555

Name

Address

Telephone

( ) 555-5555

Bank Name

Bank Address

Checking AccountSavings AccountOtherOther

YESNO

Describe:

YESNO

Describe:

PLEASE ANSWER ALL QUESTIONS, USING “NO” OR “NONE” WHERE NECESSARY

AS OF THIS DATE

Date

Cash on Hand & Unrestricted in Banks (See Sched. No. 1)

$ Amount

U.S. Government Securities

$

Accounts & Loans Receivable (See Sched. No. 2)

$

Notes Receivable, Discounted With Banks, Finance Companies, etc. (See Sched. No. 2)

$

Life Insurance, Cash Surrender Value (Do not deduct loans) (See Sched

$

Other Stocks & Bonds (See Sched. No. 4)

$

Real Estate (See Sched. No. 5)

$

Automobiles Registered in Own Name

$

Automobiles Registered in Own Name

$

Other Assets (itemize)

$

Other Assets

$

Other Assets

$

Other Assets

$

TOTAL ASSETS

$ Total

Notes Payable to Banks, Unsecured Direct Borrowings Only

$

Notes Payable to Banks, Secured Direct Borrowings Only (See Sched. No. 1)

$

Notes Receivable, Discounted with Banks, Finance Companies, etc.

$

Notes Payable to Others, Unsecured

$

Notes Payable to Others, Secure

$

Loans Against Life Insurance (See Sched. No. 3)

$

Accounts Payable

$

Interest Payable

$

Taxes & Assessments Payable (See Sched. No. 5)

$

Mortgages Payable on Real Estate (See Sched. No. 5)

$

Other Liabilities (itemize)

$

TOTAL LIABILITIES

$

NET WORTH

$

NO. 1

BANKING RELATIONS

(A list of all my bank accounts, including savings & loans)

Name and Location of Bank

Cash Balance

$

Amount of Loan

$

Maturity of Loan

How Endorsed? Guaranteed or Secured

Name and Location of Bank

Cash Balance

$

Amount of Loan

$

Maturity of Loan

How Endorsed? Guaranteed or Secured

Name and Location of Bank

Cash Balance

$

Amount of Loan

$

Maturity of Loan

How Endorsed? Guaranteed or Secured

NO. 2

ACCOUNTS, LOANS & NOTES RECEIVABLE

(A list of the largest amounts owing to me.)

Name and Address of Debtor

Amount Owing

$

Age of Debt

Description of Nature of Debt

Description of Security Held

Date Payment Expected

Name and Address of Debtor

Amount Owing

$

Age of Debt

Description of Nature of Debt

Description of Security Held

Date Payment Expected

Name and Address of Debtor

Amount Owing

$

Age of Debt

Description of Nature of Debt

Description of Security Held

Date Payment Expected

Name and Address of Debtor

Amount Owing

$

Age of Debt

Description of Nature of Debt

Description of Security Held

Date Payment Expected

NO. 3

LIFE INSURANCE

Name of Person Insured

Name of Beneficiary

Name of Insurance

Type of Policy

Face Amount of Policy

$

Total Cash Surrender Value

$

Total Loans Against Policy

$

Amount of Yearly Premium

$

YesNo

Name of Person Insured

Name of Beneficiary

Name of Insurance

Type of Policy

Face Amount of Policy

$

Total Cash Surrender Value

$

Total Loans Against Policy

$

Amount of Yearly Premium

$

YesNo

Name of Person Insured

Name of Beneficiary

Name of Insurance

Type of Policy

Face Amount of Policy

$

Total Cash Surrender Value

$

Total Loans Against Policy

$

Amount of Yearly Premium

$

YesNo

Name of Person Insured

Name of Beneficiary

Name of Insurance

Type of Policy

Face Amount of Policy

$

Total Cash Surrender Value

$

Total Loans Against Policy

$

Amount of Yearly Premium

$

YesNo

NO. 4

BANKING RELATIONS

Face Value (Bonds) Number of Shares (Stocks)

Description of Security

Registered In Name Of

Cost

Present Market Value

$

Income Received Last Year

$

To Whom Pledged

Face Value (Bonds) Number of Shares (Stocks)

Description of Security

Registered In Name Of

Cost

$

Present Market Value

$

Income Received Last Year

$

To Whom Pledged

Face Value (Bonds) Number of Shares (Stocks)

Description of Security

Registered In Name Of

Cost

$

Present Market Value

$

Income Received Last Year

$

To Whom Pledged

Face Value (Bonds) Number of Shares (Stocks)

Description of Security

Registered In Name Of

Cost

$

Type a question

Present Market Value

$

Income Received Last Year

$

To Whom Pledged

NO. 5

REAL ESTATE

(The legal equitable title to all the real estate listed in this statement is solely in the name of the undersigned, except as follows:)

Description or Street Number

Dimensions or Acres

Improvement Consistent of

Mortgages or Liens

Due Dates and Amounts of Payments

$

Assessed Value

$

Present Market Value

$

Unpaid Taxes

Year( YYYY) and Amount ($$)

Description or Street Number

Dimensions or Acres

Improvement Consistent of

Mortgages or Liens

Due Dates and Amounts of Payments

$

Assessed Value

$

Present Market Value

$

Unpaid Taxes

Year( YYYY) and Amount ($$)

Description or Street Number

Dimensions or Acres

Improvement Consistent of

Mortgages or Liens

Due Dates and Amounts of Payments

$

Assessed Value

$

Present Market Value

$

Unpaid Taxes

Year( YYYY) and Amount ($$)

Description or Street Number

Dimensions or Acres

Improvement Consistent of

Mortgages or Liens

Due Dates and Amounts of Payments

$

Assessed Value

$

Present Market Value

$

Unpaid Taxes

Year( YYYY) and Amount ($$)

I submit the foregoing information as my complete and true personal and financial condition as of the date shown below. In accordance with the Privacy Act (5 U.S.C. 552 a), Freedom of Information Act and The Fair Credit Reporting Act, I expressly authorize any past or present employer, any law enforcement agency, federal, state or local, or any person who has personal knowledge of my character, work experience or criminal records to release this information to Franchisor. If requested by Franchisor, I agree to supply statements from my professional advisors (i.e., banker, broker, accountant or attorney) verifying the above assets, and I also agree to furnish copies of Federal Income Tax Returns as filed for the last five years. I understand that Franchisor is relying upon all the above information as a material factor in considering my application to become a franchisee, and I therefore agree to promptly notify Franchisor of any material change in any of the above information or any subsequent information provided to franchisor. In addition, I release all persons from liability as a result of true, accurate information. Further, Franchisor Trade Secrets will not be disclosed by Applicants to any other person or business entity, and will not be used by Applicants in any manner outside the evaluation process, either during or after the evaluation process.

Signature*

Signature Date*

Date

Please check your information and submit once. On the next page you will receive a confirmation message of your successful submission.

Request For Consideration Form

PLEASE ANSWER ALL QUESTIONS

PERSONAL INFORMATION

APPLICANT'S FRANCHISE PLANS

EDUCATION

BUSINESS & EXPERIENCE RECORD

PHYSICAL CONDITION

INCOME

REFERENCES

Bank References

CONTINGENCIES

CONFIDENTIAL FINANCIAL STATEMENT

ASSET

LIABILITIES AND NET WORTH

SUPPLEMENTARY SCHEDULES