Name: *
Address: *
City: *
Postal Code / ZIP Code: *
Province / State: *
CDN Citizen / US Citizen: * Yes No
Date of Birth: *
Driver License Number:
Social Insurance Number / Social Security Number (Optional):
Marital Status: *
Home Phone: *
Business Phone: *
Email: *
Spouse's Name: *
Spouse's Occupation: *
Children's Names/Ages: *
Education: * Please Select Area High School College University Other
Current Business or Employer: *
Position: *
Date of Employment: *
What Were Your Major Responsibilities? *
Why Are You Looking for a New Business Opportunity? *
How Long Have You Been Looking for a Business? *
Do You Have Any Experience in Franchising? *
What is You Project Date to Start Your Business? *
What Geographical Area Have You Defined for Your Business Opportunity? * First Choice: * Second Choice: Third Choice:
Would You Be an Active Participant or a Passive Investor? *
Would you be involved in this business on a part-time or full-time basis? *
How many hours can you devote per week? *
How many hours can you devote per month? *
Do you intend to supervise this business? If not, what role will you play? *
Do You Have a Financial Partner? If Yes, Please List: *
Optional - REFERENCE 1 Name: Company Name: Address:
Optional - REFERENCE 2 Name: Company Name: Address:
Optional - REFERENCE 3 Name: Company Name: Address:
What will be your source of income to cover personal living expenses during the initial start-up? *
Assets
Cash in Chequing Account: * $
Cash in Savings Account: * $
Real Estate, Home: * $
Other Real Estate: * $
Cash Surrender of Life Insurance: * $
Stocks and Bonds: * $
Your Own Business: * $
Automobile(s): * $
Appraised Collectibles: * $
Money due You: * $
Other Assets (Please List): $
Liabilities
Notes Payable to Banks: * $
Notes Payable to Finance Companies: * $
Real Estate Indebtedness: * $
Automobile(s) Indebtedness: * $
Owing on Life Insurance: * $
Charge Accounts: * $
Tax Payable: * $
Other Liabilities (Please List): $
Source of Income
Salary: * $
Bonuses and Commissions: * $
Dividends: * $
Real Estate: * $
Other Income - Itemized: $
Are you a defendant in any suits or legal action? *
Have you ever made a composition settlement? Explain. *
Have you ever filed for bankruptcy? Explain. *
All of the information stated herein is a true and correct representation of my personal and financial condition. I authorize investigation of all statements contained in this application.
Signature (Type Your Full Name): *
Date: *
