FRANCHISE APPLICATION FORM

APPLICANT 1

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email Address*

Address*

Street Address

CityState / Province

Postal / Zip Code

PLEASE SELECT THAT APPLY

UNITED STATES CITIZENPERMANENT RESIDENTSTUDENTOTHER

DATE OF BIRTH*

EMPLOYMENT HISTORY

COMPANY*

POSITION *

DATE OF EMPLOYMENT*

FROM (MONTH/YEAR) TO(MONTH/YEAR)

RESON FOR LEAVING*

COMPANY*

POSITION *

DATE OF EMPLOYMENT*

FROM (MONTH/YEAR) TO(MONTH/YEAR)

RESON FOR LEAVING*

BUSINESS OWNERSHIP EXPERIENCE (if applicable)

BUSINESS NAME

NATURE OF BUSINESS

YEARS OF TRADE

IS THE BUSINESS STILL OPERATING?

YESNO

BUSINESS NAME

NATURE OF BUSINESS

YEARS OF TRADE

IS THE BUSINESS STILL OPERATING?

YESNO

REFERENCES

COMPANY NAME

CONTACT NAME*

Phone Number*

Area CodePhone Number

COMPANY NAME

CONTACT NAME*

Phone Number*

Area CodePhone Number

OTHER BACKGROUND INFORMATION

Have you or any applicable partners, officers, directors, or shareholders with your business affiliations ever:

Had any administrative, criminal or civil action alleging a violation of any franchise law, fraud, embezzlement, fraudulent conversation, restraint of trade, unfair or deceptive practices, and misappropriation of property or comparable allegations? Please note that FISHWAVE reserves the right to request a copy of your criminal record from the relevant State Police Authority.*

YESNO

Been convicted of a felony or pleaded “no contest” to a felony charge or been held liable in a civil action by a final judgement or been the subject of a material complaint or other legal proceeding such as a felony, civil action complaint, misappropriation of property or comparable allegations?*

YESNO

Been adjudged bankrupt or reorganized due to insolvency?*

YESNO

If you answered “Yes” to any of the questions above, please explain:

GENERAL INQUIRY

ARE YOU PREPARE TO COMPLY WITH THE PROCEDURES AND CONTROLS SET BY Grime Task Force?*

YESNO

Why do you think you will be successful?*

Are your intentions to work full time in the business?*

YESNO

Are you aware certain information provided and/or advised to you is confidential and shall not be divulged to any third person unless Grime Task Force gives approval?*

YESNO

FINANCE INFORMATION(MONTHLY)

	INCOME
SALARY 1
SAlARY 2
SHARES
INVESTMENT
OTHERS
TOTAL

FINANCE INFORMATION(MONTHLY)

	EXPENCES
MORTAGE 1
MORTAG 2
CAR LOAN 1
CAR LOAN 2
CREDIT CARD 1
CREDIT CARD 2
GENERAL LIVING EXPENCES
OTHERS
TOTAL

HOW ARE YOU FUNDING THIS OPPERTUNITY?

	MONTHLY REPAYMENT
CASH
HOME EQUITY
BUSINESS LOAN
OTHER
TOTAL

Acknowledgment & Authorisation

All information contained herein is confidential and is strictly for the purpose of facilitating the Grime Task Force franchise application process. Grime Task Force is not a party to this sale of business transaction and makes no representation of warranty as to the accuracy or completeness of the information provided. Any information or comments provided to you do not constitute financial advice. Grime Task Force cannot estimate earnings for franchised business and does not make forecasts or projections. The submission of this application does not obligate either the applicant or Grime Task Force in any manner, nor does it imply that there is a legal or commercial relationship between either party. Grime Task Force reserves the sole right to approve or disapprove the application for any reason it may determine, and in the event that Grime Task Force disapproves the application, it shall have no liability to the undersigned. It is merely a preliminary procedure. Acknowledgement is made that the information supplied by me is true and correct. I hereby authorize Grime Task Force to obtain any information about my credit history or other information that it deems appropriate to evaluate my suitability as a prospective Grime Task Force Franchisee.

Declaration for Mail, Emailed and Faxed Applications

I/WE*

OF(ADDRESS)*

1. I/We have answered the questions and provided the information in this form to the best of my/our knowledge and belief, and that as far as I am/we are aware the answers and information are true and correct in all respects and that no relevant details have been omitted.
2. I/We acknowledge that if any information included in this Application is false or misleading in anyway Grime Task Force shall have the right to terminate any franchise agreement entered into on the basis of the information contained in this Application

I/We also acknowledge and agree that Grime Task Force:

1. Is collecting the information contained in this Application to assess whether I/we should beconsidered as a potential franchisee;
2. Is relying upon the information contained in this Application as a material factors in considering this Application
3. Is authorised to contact any appropriate third parties to verify the accuracy of the information in the application, and to retain any information obtained for its records;
4. May provide the information contained in this Application to its advisors, including its accountants, lawyers and consultants; and
5. May retain copies of this Application for its records, whether or not this Application is successful

Dated this*

Date

For Electronic Applications:
By submitting this application electronically, I agree to the above statements.

APPLICANT Print Full Name

APPLICANT Signature *

FRANCHISE APPLICATION FORM

ATTENTION : FRANCHISING DEPARTMENT