This is not a contract and supplying or completing this form incurs no obligations on either party.
If at first address for less than five years, please provide a previous address.
Give a complete record of your experience, beginning with your present or last position. Include military service. Indicate by asterisk (*) those employers you do not wish us to contact.
Please list three professional and character references.
Please list three credit references.
A list of all my bank accounts, including savings and loans.
A list of the largest amounts owing to me.
The legal equitable title to all real estate listed in this statement is solely in the name of the undersigned, except as follows:
List any additional notes, comments, or information that didn't fit in the fields above.
I submit the foregoing information as my complete and true personal financial condition as of the date shown below. In accordance with the Privacy Act (5 U.S.C. 552 a), Freedom of Information Act and The Fair Credit Reporting Act, I expressly authorize any past or present employer, any law enforcement agency, federal, state, or local, or any person who has personal knowledge of my character, work experience or criminal records to release information to the Franchisor. If requested by the Franchisor, I agree to supply statements from my professional advisors (i.e. banker, broker, accountant or attorney) verifying the above assets, and I also agree to furnish copies of Federal Income Tax Returns as filed for the last five years. I understand that the franchisor is relying upon all of the above information as a material factor in considering my application to become a franchisee, and therefore agree to promptly notify the Franchisor of any material change in any of the above information or any subsequent information provided to franchisor. In addition, I release all persons from liability as a result of true, accurate information. Further, Franchisor Trade Secrets will not be disclosed by Applicants to any other person or business entity, and will not be used by Applicants in any manner outside the evaluation process, either during or after the evaluation process.