Franchise Application

Transcription

1 Franchise Application Youthland Academy 9352 Main Street Cincinnati, Ohio Office: Fax:

2 Confidential Personal Profile: Are you a US Citizen? yes no If no, what Country: Full Name: _ Social Security #: - - Address: City: State: Zip: Spouse's Name: Home Phone: Business Phone: Social Security #: - - Confidential Information: Have you ever owned a business? yes no (If yes, please explain:) Have you ever owned a child care business or worked in the field? (If yes, please explain:) Do you have any educational or special training? yes no (If yes, please explain:) What interested you about our opportunity? How did you learn about our franchise opportunity? What is your time frame for opening your business? Why would you like to be in business for yourself? Business & Educational Experience: Your Employer: Position: Annual Income: $ Level of Education: High School: College: Graduate School: Major: Degree:

3 Spouse's Employer: Position: Annual Income: $ Level of Education: High School: College: Graduate School: Major: Degree: Legal Information: Have you or your spouse ever filed for personal and/or business bankruptcy protection? yes no Have you ever been convicted of a felony or misdemeanor? yes no Are you a named party in any pending litigation? yes no Are there any judgments against you or a business you control? yes no Financial Information: Assets Liabilities Cash on Hand $ Notes Payable $ Savings $ Accounts Payable $ Home Market Value $ Home Mortgage $ Other Real Estate $ Other Mortgage $ Automobiles $ Automobile Loans $ Cash Value of Life Insurance $ Loans Against Life Insurance $ Stocks, Bonds & Securities $ Credit Cards $ Other (Please Itemize) $ Other (Please Itemize) $ Total Assets: $ Total Liabilities: $ Total Assets (from above): $ Less Total Liabilities (from above): $ Total Net Worth: $ Estimated Credit Score: Your Spouse:

4 Please Identify Sources of Capital Used To Fund a Youthland Academy Franchise* Liquid Assets Equity Sources (Please describe: cash, stocks, securities, etc.) (Please describe: cash, stocks, securities, etc.) Description Value $ Description Value $ Total: $ Total: $ *Additional information may be requested Business & Credit References: Business References: Name Home Phone Mobile Phone Credit References: Company Name Address Phone Number

5 Please contact Youthland Academy with any questions (513) I hereby authorize Youthland Academy to procure a consumer report and /or investigative consumer report and/or criminal background check on me ( Reports ). These Reports may include, without limitation, information as to my character, general reputation, personal characteristics and mode of living, which may be obtained through employment and education verifications; my personal credit history received from any credit bureau; my driving history, including any traffic law violations; personal references and/or interviews; a social security number verification; present and historical addresses; criminal and civil history/records; and any other public records. I authorize any person, individual, business entity or governmental agency who may have information relevant to the Reports, including any and all court, administrative tribunals, public & law enforcement agencies and credit bureaus, to disclose the same to Youthland Academy regardless of whether such person, individual, business entity, governmental agency or credit bureau obtained the information itself or from other sources. I hereby release and fully discharge Youthland Academy and its members, affiliates, officers, directors and employees, from any and all liabilities, claims, debts, costs, actions, causes of action and/or demands, by me, my heirs or others making such claim or demand on my behalf, regarding the use or disclosure of the information presented above, as well as the provisions of any consumer report and/or investigative consumer report and/or criminal background check authorized hereby. I understand that this Authorization/Release form shall remain in effect for the duration of my business relationship with Youthland Academy. I hereby certify that the information presented herein is true and accurate. I understand that my application for a franchise will be terminated as a result of any false, misleading, omitted or fraudulent information. Applicant Signature: Applicant Signature: Received By: