|
Full Name
Social Security #
Email Address
Name of Franchise
|
| Address
City
State
Zip
|
|
How Long at Address?
Age
Home Phone #
|
| Marital status
Spouse's Name
|
| Employer
Type of business
|
| Business Address
Business Phone
|
| Position
Salary
Other Income
|
| Spouse's Occupation
How Long?
No. of Dependents
|
| Home:
If renting, name of landlord
|
| Education:
Name of College
Degree(s)
|
| Last Address, if
more than 12 months
|
|
PREVIOUS
BUSINESS EXPERIENCE
(Last prior occupations or business owned)
|
| Firm Name
City
Position or type business
Period
|
| Firm Name
City
Position or type business
Period
|
| Firm Name
City
Position or type business
Period
|
|
CREDIT
IS ESTABLISHED WITH THE FOLLOWING FIRMS
(Give name of supplies or persons with whom you have credit)
|
| Name
Address
Type credit
Max. amt
|
| Name
Address
Type credit
Max. amt
|
| Name
Address
Type credit
Max. amt
|
| Name
Address
Type credit
Max. amt
|
|
PERSONAL
REFERENCES - (Not Relatives)
|
| Name
Address
Occupation
Telephone
|
| Name
Address
Occupation
Telephone
|
| Name
Address
Occupation
Telephone
|
| How did you learn
about our franchise?
Available Capital to Invest
|
| When will you be
available?
Will you have a partner? If so, provide name
|
| What is your location
preference
|
|
PERSONAL
FINANCIAL STATEMENT
(Please answer all questions using "No" or "None"
where necessary)
|
| Assets |
| Cash on hand, and
unrestricted in banks
U.S. Government Securities
|
| Accounts and loans
receivable
Notes receivable, not discounted
|
| Notes receivable,
discounted with banks, finance companies, etc.
|
| Life insurance, cash
surrender value (Do not deduct loans)
|
| Stocks & Bonds
Real Estate
Automobiles (in your name)
|
| Other Assets (Please
itemize)
|
|
Total Assets
|
| Source
of Income |
| Salary
Bonus & Commissions
Dividends
|
| Real Estate
Other Income (Itemize)
|
| Total
|
| Liabilities
& Net Worth |
| Notes payable to
banks, unsecured
Notes payable to banks secured
|
| Notes payable to
others, unsecured
Notes payable to others, secured
|
| Loans against life
insurance
Accounts payable
|
| Interest payable
Taxes & Assessments payable
|
|
Mortgage payable
on real estate
Brokers margin accounts
|
| Other liabilities
(itemize)
Total Liabilities
|
| Total Assets - Total
Liabilities = Net Worth
|
| Contingent
Liability |
| As endorser of co-maker
In lease or contracts
|
| Legal claims
Provision for Fed. Income Tax
|
|
Other special debts
|
|
|
