FCC CONFIDENTIAL QUESTIONNAIRE

YOUR INFORMATION
Name*

First NameLast Name
Age
Spouse's Name

First NameLast Name
Spouse's Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Best Time To Call?
Your E-mail*
example@example.com
Your Consultant's Name*

First NameLast Name
Your Consultant's Email (Please Verify Spelling)*
CHILDREN
How Many?
What Ages?

PROFESSIONAL INFORMATION
Your Occupation
Employer
Position
Income
Your Spouse's Occupation
Employer
Job Title
Income
BUSINESS EXPERIENCE
Have you ever owned a business?
How long have you been looking for a business?
Why are you looking now?
What else would you like to discuss?

RATE YOUR FRANCHISE KNOWLEDGE
What have you looked at?
What did you like?
Why did you like it?
#1 most important attribute of a business? (Other than Profit.)
Time frame for being in business?
Who will make the decision?
WHERE DO YOU WANT TO OPEN A BUSINESS? (i.e. Summit, NJ or ORANGE COUNTY, CA)
Location #1
Location #2
Location #3
Other?

JUDICIAL INFORMATION
Have you or your spouse been involved in a bankruptcy?
Have you or your spouse been convicted of a crime?
Are you under any type of criminal investigation?
Are you or your spouse subject to any civil lawsuits or judgements?
Please explain any affirmative answers to the previous questions.

FINANCIAL STATEMENT
ASSETS
Cash (Checking & Savings)
Stocks, Bonds, CDs
Home Market Value
Retirement Accounts
401k
IRA
Autos
Personal Property
Money Due You
Life Insurance
Pensions
Other Assets
Total Assets

LIABILITIES
Credit Card Debt
Auto Debt
Mortgage Outstanding
Line of Credit
Accounts Payable
Other Debts
Total Liabilities
Net Worth (Total Assets - Total Liabilities)

FINAL THOUGHTS ON FINANCING
Cash Available for Investment?*
Credit Score*
Do you plan to have a partner?
Do you plan to have investors?
Will partners / investors be active in the business?
Other thoughts?