Fields marked with * are mandatory.

Personal Information

*First Name: *Last Name: Date:
*Email: Gender: Present Address:
Male Female
Home Phone: Mobile Phone: Work Phone:
Work Phone Extension: *City: *Country:
*State / Province: *Zip / Postal Code: Birth Date:
Best Time To Call: Home Ownership: Marital Status:
Own Renting Single Married
Spouse Name: Spouse Birth Date:

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:


Annual Sources of Income

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