| Name: |
|
| Email Address:
|
|
| Social Security #
|
|
| DATE OF BIRTH:
|
|
| ADDRESS: |
|
| CITY: |
|
| PROVINCE/STATE:
|
|
| POSTAL/ZIP CODE:
|
|
| HOME TEL: |
|
| CELL TEL: |
|
| LENGTH AT PRESENT
ADDRESS? |
|
| Own / Rent? |
Own
Rent
|
| ARE YOU A CITIZEN:
|
Yes
No |
| IF NO, PLEASE GIVE PLACE
OF PERMANENT RESIDENCE AND YOUR IMMIGRATION
STATUS: |
|
| MARITAL STATUS
|
|
| SPOUSE’S NAME:
|
|
| WILL SPOUSE BE ACTIVE IN
THE BUSINESS: |
|
| IF YES, Full Time?
|
|
| SPOUSE’S OCCUPATION:
|
|
| NO. OF CHILDREN:
|
|
| AGES: |
|
| HOW MUCH TIME WILL YOU
DEVOTE TO THIS BUSINESS? |
Full Time
Part Time |
| WILL THERE BE ANY OTHER
PARTNERS IN THIS BUSINESS? |
YES
NO |
| HOW MUCH TIME WILL THE
PARTNERS DEVOTE TO THIS BUSINESS? |
Full Time
Part Time |
| NAME OF PARTNER(S)
|
|
| YOUR PERCENTAGE OF
OWNERSHIP: |
|
| SPOUSE PERCENTAGE OF
OWNERSHIP: |
|
| PARTNER 1 PERCENTAGE OF
OWNERSHIP: |
|
| PARTNER 2 PERCENTAGE OF
OWNERSHIP: |
|
| LIST ANY HOBBIES,
COMMUNITY ACTIVITIES, SPECIAL INTERESTS:
|
|
| (PLEASE CIRCLE LAST YEAR
OF SCHOOL COMPLETED) HIGH SCHOOL |
9
10
11
12 |
| COLLEGE/UNIVERSITY-number
of year attended |
1
2
3
4 |
| NAME OF COLLEGE:
|
|
| LIST ANY COURSES RELATED
TO RETAIL SALES OR MANAGEMENT: |
|
| HOW DID YOU HEAR ABOUT
ENVIROSPECT™? |
|
| PLEASE LIST THE
GEOGRAPHIC AREAS OF INTEREST TO YOU FOR AN
ENVIROSPECT™ LOCATION |
|
| ARE YOU WILLING TO
RELOCATE? |
YES
NO |
| IF YES, WHERE?
|
|
| HAVE YOU EVER BEEN
SELF-EMPLOYED: |
YES
NO |
| IF YES, WHAT WAS THE
BUSINESS? |
|
| HAVE YOU EVER DECLARED
PERSONAL BANKRUPTCY OR HAD A BUSINESS FAILURE?
|
YES
NO |
| IF YES, STATE THE REASON,
PLACE AND DATE OF DISCHARGE: |
|
| HAVE YOU EVER BEEN
CONVICTED OF A CRIMINAL OFFENSE? |
YES
NO |
| IF YES: |
STATE
FEDERAL |
| IF YES, EXPLAIN:
|
|
| NAME, ADDRESS AND
TELEPHONE OF LAWYER ACTING ON YOUR BEHALF FOR THE
TRANSACTION: |
|
| NAME, ADDRESS AND
TELEPHONE OF YOUR ACCOUNTANT: |
|
| MAY WE CONTACT YOUR
PRESENT EMPLOYER? |
YES
NO |
| COMPANY |
|
| ADDRESS |
|
| TYPE OF BUSINESS:
|
|
| POSITION |
|
| SALARY |
|
| EMPLOYED FROM
|
|
| TO |
|
| SUPERVISOR |
|
| TELEPHONE |
|
| DESCRIBE YOUR
DUTIES/RESPONSIBILITIES: |
|
| PLEASE PROVIDE US WITH A
BRIEF OVERVIEW OF YOUR BUSINESS EXPERIENCE,
PERSONAL PLANS AND WHY YOU ARE INTERESTED IN AN ENVIROSPECT™ FRANCHISE. ALSO, PLEASE OUTLINE YOUR EXPECTATIONS OF
OWNING AN ENVIROSPECT™ FRANCHISE. |
|
| I hereby present
EnviroSpect™ with the most current and accurate
financial information as of ,_______(INSERT DATE)
2005. |
|
| CASH ASSETS
|
|
| SECURITIES |
|
| REAL ESTATE
|
|
| OTHER ASSETS
|
|
| BANK LOANS LIABILITIES
|
|
| MORTGAGE |
|
| OTHER LOANS
|
|
| BILLS PAYABLE
|
|
| HOW MUCH CASH WILL BE
AVAILABLE TO INVEST INTO AN ENVIROSPECT™
FRANCHISE? |
|
| WHAT WILL BE THE SOURCE
OF CAPITAL FOR AN ENVIROSPECT™ FRANCHISE?
|
|
| CURRENT INCOME (NET
MONTHLY INCOME) SALARY |
|
| CURRENT INCOME (NET
MONTHLY INCOME)SPOUSE’S SALARY: |
|
| CURRENT INCOME (NET
MONTHLY INCOME) OTHER INCOME |
|
| NET MONTHLY INCOME
|
|
| CURRENT EXPENSES (NET
MONTHLY AMOUNT) RENT OR MORTGAGE: |
|
| CURRENT EXPENSES (NET
MONTHLY AMOUNT) UTILITIES: |
|
| CURRENT EXPENSES (NET
MONTHLY AMOUNT) REALTY TAXES: |
|
| CURRENT EXPENSES (NET
MONTHLY AMOUNT) CAR EXPENSES : |
|
| OTHER EXPENSES
|
|
| TOTAL MONTHLY EXPENSES
|
|
| I hereby certify that all
information provided in this application is true
and correct as of the date below. I authorize
EnviroSpect™ and its Affiliates or agents to
conduct any necessary credit checks and hereby
waive my right conferred upon me by statute or
otherwise regarding any disclosures obtained by
EnviroSpect™ or its affiliates or agents.
|
YES
NO
|
| I understand that any
false information or consequential omission
contained in this application would be cause for
immediate termination of any subsequent agreement
reached between myself and EnviroSpect™.
|
YES
NO
|
| For U.S. prospective
franchisees: Our acceptance of this confidential
franchise application form shall not constitute an
offer to sell or the solicitation of any offer to
buy an EnviroSpect™ franchise, nor shall there be
any offer or sale of such franchises in any state
in which such offer or sale would be unlawful
prior to registration of this franchise under the
laws of such state. An offer may be made only
under our then-current uniform franchise offering
circular. |
YES
NO
|
| I hereby certify that all
information provided in this application is true
and correct as of the date below. (ENTER DATE in
Form)
|
|
| I authorize EnviroSpect™
and its Affiliates or agents to conduct any
necessary credit checks and hereby waive my right
conferred upon me by statute or otherwise
regarding any disclosures obtained by EnviroSpect™
or its affiliates or agents. (ENTER FULL NAME)
|
|
| |
