Name*
Name: (spouse)
Address*:
Address:
City*:
State*:
Please select
Alabama
Alaska Arizona
Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii
Idaho Illinois Indiana Iowa
Kansas Kentucky Louisiana Maine Maryland
Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New
Hampshire New Jersey
New Mexico New York North Carolina North Dakota Ohio Oklahoma
Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S.
Virgin Islands Utah Vermont Virginia Washington (State) Washington,D.C. West Virginia Wisconsin Wyoming
Zip*:
Marital status:
Please select
Single
Married
Divorced
Widowed
Phone (day):*
Phone (evening):
Phone (cell ):
How did you first hear about our opportunity?*
Please select
BeTheBoss
BeTheBoss - Canada
Destiny Group - Vetfran
Classified ad
Direct mail
FranchiseSolutions.com
FranchiseWorks.com
IFA
Internet search
Internet/website
JCK
Modern Jeweler
National Jeweler
Other
Referral from franchisee
Referral from friend or relative
Have you visited one of our locations?*
Please select
Yes
No
I
am most interested in:*
Please select
Multi unit
Other
Single unit
Market / city choice one:
Market / city choice two:
Market / city choice three:
EDUCATION
School attended:
Years:
Degree:
EMPLOYMENT
Current employer:*
Years:*
Address:*
Position:*
Contact at work?
Yes
No
PERSONAL BUSINESS DETAILS
What personal goals
would you like to achieve by owning your own business?* Rank the
most important with a 1 and the least important with a 10. Use
numbers 1 through 10 only once.
Control of future
Build a business
Personal
g rowth
Flexibility of time
Family involvement
Community
Income level
Build to sell
Be my own boss
How would you rate your business skills?
Sales:*
Please select
Excellent
Very Good
Good
Fair
Poor
Management:*
Please select
Excellent
Very Good
Good
Fair
Poor
Organization:*
Please select
Excellent
Very Good
Good
Fair
Poor
Finance:*
Please select
Excellent
Very Good
Good
Fair
Poor
Marketing:*
Please select
Excellent
Very Good
Good
Fair
Poor
Customer service:*
Please select
Excellent
Very Good
Good
Fair
Poor
Have you owned your own business before?*
Please select
Yes
No
If yes, please explain:
How soon would you like to start this business?*
Please select
Immediately
3_to_6_months
7_to_12_months
1_year+
PERSONAL
INFORMATION:
CASH
(checking & savings)
Notes payable
banks
Stocks / bonds
Other:
CDs
Other:
Accounts/notes receivable
Other:
Real estate -
home
Credit card debt
Real estate -
other
Real estate -
other
Automobiles
Auto debt
Other accounts
payable
Personal property
Mortgage - home
Retirement accounts: IRA
Line of credit
401 (k)
Other
Other
Other
Other
Unpaid real estate taxes
Unpaid income taxes
Secured loans
Other
TOTAL ASSETS*
TOTAL
LIABILITIES*
NET WORTH*
Yearly income from present occupation:*
Other yearly income:
Spouse's yearly income:
Spouse's present occupation:
Minimum income needed to maintain current lifestyle:*
Would this business be your only source of income?*
Please select
Yes
No
If no, please explain:
Do you intend to run this business yourself?*
Please select
Yes
No
If no, please explain:
Have you every been convicted of a felony?*
Please select
Yes
No
If yes, please explain:
Have you ever declared bankruptcy?*
Please select
Yes
No
If yes, please explain:
I certify that the
information I have submitted on this form is complete and
correct. I understand that the information I
am providing is confidential and will not be shared with
anyone without my permission and will be held in strict
confidence. I hereby grant permission to contact or
procure my consumer report and/to obtain information concerning
my credit, criminal, motor vehicle, state and/or local
governmental agencies and other pertinent history prior to
granting a franchise. If there is a
partner involved in this business, I understand that he/she/they
will also be required to complete this
form as well prior to being granted a franchise.Please enter your email address to show that
you agree with the above statement*:
