PRELIMINARY
INFORMATION SHEET
Directions: Please print and fill out all sections of this
sheet. The information requested herein is for initial evaluation of your
qualifications as a franchisee and will be kept strictly confidential. Completion
of this sheet is not an offer to purchase a franchise and does not obligate
you in any way. Should you elect to purchase a franchise, you may be required
to furnish additional information.
Date Social Security Number
Name
Age Spouse’s name Age
Address City State Zip
Home phone ( ) Business phone ( )
If necessary, may we contact
you at your place of business? Yes
No
Best time to contact
you_________ (a.m.)__________ (p.m.)
Marital Status: Single
Married Divorced Children (number)
Ages of children Do you have any health problems? If so, please
describe
Does your spouse have any
health problems? If so, please describe.
Desired area for franchise
(city and state)
Second choice of location
(city and state)
Part II. Education
School Name of
school, city, state Last year
completed Last yr. attended
Major Degree
High School 9
10 11 12
Mo. 19
College
1 2
3 4 Mo. 19
College 1
2 3 4 Mo. 19
Part III. Employment History
Please use the spaces below
to list employment history within the past five years, or three positions held,
starting with most current position.
Dates Income Company Address Position
1. to
2. to
3. to
4. to
5. to
6. to
Part IV.
Financial Information
ASSETS LIABILITIES:
Checking and Savings $
Notes Payable - Banks.
$
Stocks and Bonds $ Notes
Payable - Others $
Real Estate Owned (Home) $ Real
Estate Mortgages Payable (Home) $
Real Estate Owned (Other) $ Real
Estate Mortgages Payable (Other) $
Other assets $
Others $
$
$
$ $
$ $
Total Liabilities $
Net Worth
$_________________
Total Assets Total
Liabilities/net Worth $
Explanations:
Other Sources of Income:
Will you finance this
business venture by cash or loan? If a
loan, what is the collateral?
If borrowed from individual,
give name, address and occupation. _________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Part IV. References
Personal Name Occupation Address Phone
1.
2.
3.
Credit
Name Type of Account Address Phone
1.
2.
3.
Part V. Other
Have you ever owned or do you
presently own a business? If so, please
give details.
Have you ever made
application for a bond which was refused?
Have you ever filed for
bankruptcy, had a real estate loan foreclosed, or had any liens against you? If
so,
please explain.
Have you ever been or are you now a party to any
lawsuits? If so, please explain.
Have you ever been convicted
of any offense? Include traffic
violations for which you were fined $50
or more. If so, explain in full, including date,
charge, place, under what name and action taken. Use
additional paper if
necessary.
I understand that the
information provided is confidential and affirm that it is true to the best of
my knowledge. I understand that
providing this information does not obligate me to purchase a franchise, nor
does it obligate the
franchisor to offer a franchise to me. I authorize [FRANCHISOR] to check my
credit and employment history (including obtaining a credit report), to update
that information from time to time, and to conduct such other investigations as
are reasonably necessary to verify the information contained in this
Preliminary Information Sheet, including, without limitation, to conduct a
personal background investigation. By submitting this Preliminary Information
Sheet to [FRANCHISOR], I am agreeing to the above terms.
Signature Date