Franchise Evaluation Form

Applicant's Name
Last First Middle
Address
Street City State Zip Code

Home Phone Work Phone: Mobile Phone: Email Address

Current Employer
Name City State Phone

Position Date of Employment - From To

Social Security Number Driver's License Number Marital Status

Date of Birth (MM/DD/YY) No. of Dependents Spouse's Name

Are you a U.S. Citizen?

Previous Employers
Name City State Phone
From: To: Position        
Name City State Phone
From: To: Position        
Name City State Phone
From: To: Position        

General Education
What is your highest grade completed? Additional Degrees

Other Principals and Management
Individual Address Percentage Ownership   Percentage Time  
%
%
%
%
%
%

Personal and Professional References
Name Address Telephone Relationship

Monthly Income
Salary, Wages
$
Bonus, Commissions
$
Dividends, Interest
$
Real Estate Income
$
Notes/Accounts Receivable
$
Other Income
$
 
Total Monthly Income: $

Assets and Liabilities
Assets   Liabilities  
Cash $ Secured notes payable to others $
Marketable securities $ Unsecured notes payable to others $
Non-readily marketable securities $ Accounts payable $
Accounts and notes receivable $ Margin accounts $
Net cash surrender value of life insurance $ Notes due: partnership $
Residential Real Estate $ Taxes Payable $
Real estate investments $ Mortgage debt $
Partnership/PC interests $ Life insurance loans $
IRA, profit sharing, other vested retirement accounts $ Other liabilities $
Deferred income $    
Personal property $    
Other Assets $    
       
Total Assets $ Total Liabilities $
    TOTAL NET WORTH $

Will this franchise be your sole source of income?

Total unencumbered liquid capital readily available for use in the franchise business: $

What is the source of this unencumbered liquid capital?

How do you anticipate financing the balance of the total initial investment?

How many hours per week do you anticipate working in your business?

In what city and state would you like to open your franchise?

Would you be willing to consider other areas to open your franchise? What areas?

How soon would you be prepared to open your franchise?

When would you be available to meet with one of our representatives?

What questions would you like answered during your meeting with our representative?

By emailing or faxing this document, I hereby certify that the information supplied in this Franchisee Evaluation Form and other financial statements made by me are true and correct. I agree to have all information confirmed by one of your representatives and I authorize you to check references and conduct such additional credit checks as deemed necessary. I further understand that submission of this information does not obligate either of the parties to purchase or sell a franchise.