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*
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Personal Information
*
First Name:
*
Last Name:
Date:
*
Email:
Gender:
US Citizen:
Male
Female
Yes
No
Present Address:
Social Security #:
Home Phone:
Home Phone Extension:
Work Phone:
Work Phone Extension:
*
City:
*
Country:
*
State / Province:
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USA
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*
Zip / Postal Code:
How long at this address? (Yrs):
Previous Address:
City:
Country:
State / Province:
Select Country
Algeria
Argentina
Australia
Austria
Belgium
Brazil
Canada
China
Cyprus
France
Germany
India
Italy
New Zealand
Pakistan
Poland
South Africa
South Korea
Thailand
United Kingdom
USA
Zimbabwe
Select State
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip / Postal Code:
Birth Date:
Best Time To Call:
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23.00
Home Ownership:
Marital Status:
Spouse Name:
Own
Renting
Single
Married
Spouse Social Security #:
Spouse US Citizen:
Spouse Birth Date:
Yes
No
Select Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Select Date
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31
Assets & Liabilities
ASSETS
LIABILITIES
Cash on Hand & in Banks (CAD):
Mortgages (CAD):
Marketable Securities (CAD):
Accounts Payable (CAD):
Accounts / Notes Receivable (CAD):
Notes Payable (CAD):
Retirement Plans (CAD):
Loans on Life Insurance (CAD):
Real Estate (CAD):
Credit Cards (Total Balance) (CAD):
Personal Property (CAD):
Unpaid Taxes (CAD):
Business Holdings (CAD):
Life Insurance (CSV) (CAD):
Other Assets (CAD):
Other Liabilities (CAD):
Description:
Description:
Total Assets:
Total Liabilities:
Total Net Worth:
Real Estate Owned
Real Estate 1
Address:
Date Purchased:
Original Cost:
Present Value:
Mortgage Balance:
Real Estate 2
Address:
Date Purchased:
Original Cost:
Present Value:
Mortgage Balance:
Real Estate 3
Address:
Date Purchased:
Original Cost:
Present Value:
Mortgage Balance:
Annual Sources of Income
Salary (CAD):
Investment (CAD):
Real Estate Income (CAD):
Other (CAD):
Description:
Total (CAD):
Total Contingent Liabilities
Loan Co-signature:
Legal Judgment:
Income Taxes:
Other Special Debt:
Total:
Specific Data
When would you be ready to invest in your franchise if you were approved?:
What skills/experience do you have that will help you be successful in this business?:
Why do you think this franchise will enable you to reach your personal goals?:
Who will be responsible for the daily operation of your store?:
Amount of cash available for investment?:
Have you been approved for financing?:
Yes
No
Amount Approved (CAD):
Would this business be your sole income source?:
Do you have any contingent liabilities for guarantees, endorsements, leases etc ?:
Yes
No
Yes
No
Are you now, or have you ever been party to any lawsuit - either as defendant or plaintiff ?:
Have you ever been convicted of any offense (including misdemeanors for which you have fined CAD 200 or more) ?:
Yes
No
Yes
No
Have you ever been convicted of a felony?:
If so, explain:
Yes
No
Have you ever filed for bankruptcy?:
Date Filed:
Date Discharged:
Yes
No
Area / Location Preferences
Preference 1:
Preference 2:
Preference 3:
Please list the three main questions you have about this business opportunity
Question 1:
Question 2:
Question 3:
