FRANCHISE QUALIFICATION REPORT

Transcription

1 Primo Franchising, Inc 610 Ryan Avenue, Building V-4 Westville, NJ PH: Fax: Revised 1/25/2017 PERSONAL INFORMATION Date: FRANCHISE QUALIFICATION REPORT Name: Address: City: State: Zip: Day Phone: Evening Phone: Date of Birth: Marital Status: Number of Children: Total Number of dependents: Spouses Name: Spouses Occupation: EDUCATION High School: Graduated (date): College: Graduated: Degree: Other: Graduated: Degree: Special Training: Military Experience/Branch/Rank: BUSINESS EXPERIENCE Present or Last Occupation: Name of Company: Date Started: Address: City: State: Zip: Title & Function:

2 - 2 - Previous Employment Title, Function & Starting Dates: Have you owned or been a partner in a business? Yes: No: If yes, provide the name of the business, the dates of ownership, your percentage of ownership, and a description of the type of line of business: Do you have a financial partner, or any other personal source of investment capital? Yes: No: If Yes, please explain and note that person must prepare this type of form: How did you hear about Primo Hoagie? Do you have any Judgments, Liens or Suits Pending? Include both personal and business in which you were an owner, partner, or shareholder. Provide a description, date filed, and names of other parties: Have you filed or been the subject of any Judgments, Liens or Suits? Include both personal and business in which you were an owner, partner, or shareholder. Provide a description, date filed, names of other parties, disposition date and disposition: Have you personally filed for bankruptcy at any time? Yes No If Yes, provide for each filing, the Date of filing, Disposition Date, and the Disposition. Has any business in which you were an owner, partner, or shareholder filed for bankruptcy at any time? Yes No If Yes, provide for each filing, the Date of filing, Disposition Date, and the Disposition. Do You Have a Source for Financing? Yes No If So, Who?

3 - 3 - Have You Been convicted of a Felony? Where do you want to locate? 1 st : 3 rd : 2 nd : If Qualified, When Would You be Ready to Invest in Your Franchise? Do You Want To Supplement or Replace Your Current Income? How Much of Your Personal Savings Are You Willing to Invest? Will You Devote Full-Time? If Not Who Will Manage? Interested in Multiple or Single Location? How Long Have You Been Seriously Looking for a Business? What Kind of Businesses Have You Looked At? What Other Franchises Have You Investigated? Are you a citizen of the United States, and if not, what is the status of your US residency? What is Motivating You to Buy a Business? Add additional information you want us to know: FINANCIAL INFORMATION Please provide the following financial information. [The company reserves the right to request documentation to support the information provided. The documentation requested could include, but is not limited to, the following: Tax Returns, Bank statements, Investment Statements of Accounts, Copy of Deeds, Mortgage Statements, Loan Statements, Credit Card Statements, Articles of Incorporation, and IRS Forms K-1]

4 - 4 - FINANCIAL INFORMATION CURRENT INCOME Salary: Company Name Estimated Monthly Income Interest/Dividend Income (Bank Accounts, Mutual Funds, Stocks, Bonds ) : Estimated Monthly Income Business Income: Business Name Estimated Monthly Income Other Sources of Income: Estimated Monthly Income Total Estimated Monthly Income

5 - 5 - Current Bank Account s Other Cash on Hand (Not in Bank Accounts) Investment Accounts Real Estate Businesses City/State Vehicles / Boats / Planes Personal / Business Whole Life Insurance Policies Other Assets Bank Name Name Date Purchased Name ASSETS Type of Account Type of Account Purchase Price Ownership % Date Date Date Ownership Acquired Year Purchased Current Value Owned Amount Amount Market Value Total Business Assets Equity Current Cash Value Current Value TOTAL ASSETS

6 - 6 - LIABILITIES Mortgages Other Loans Creditor Name Credit Cards Liens / Judgments / Child Support Other Liabilities Holder Name Name Type of Loan Remaining Remaining Remaining Amount Owed Amount Total Liabilities NET WORTH Total Assets Less: Liabilities Net Worth

7 - 7 - By signing this form, you authorize us to conduct investigation into my work and financial history, including a search of my credit history. My social security number is: _ I certify that my answers are true and correct under the laws of the United States of America.. Signature

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