Personal Information
Todays Date:
Citizen of:
Last Name:
First Name:
Middle Initial:
Social Security #:
Other names known by:
Are you of legal age in your state:
Spouses Information
Last Name :
First Name:
Middle Initial:
Social Security #
Other names known by:
Are you of legal age in your state:
Contact Information
Telephone (Home):
Fax:
Present Address:
Present Address Country:
City:
State/Province:
Zip/Postal Code:
How long:
E-mail Address:
Educational Background
Schools Attended/Years Attended/Grade or Degree Attained:
Business Information
Self Employed?
Type of Business:
How Long:
Business Phone:
Mobile Phone:
Fax:
What do you like most about your existing business?
What do you like least about your existing business?
Employment History
Employed by:
# of Years:
Address:
City:
State/Province:
Zip/Postal Code:
Position Held:
Nature of Business:
May you be contacted at work?
Have you ever been convicted of a felony?
Income Information (please
use US dollars)
Income from Present Occupation:
$
Other Income:
$
If other income, please explain:
Personal Bank Branch Address:
City:
State/Province:
Zip/Postal Code:
Specific Data
Estimated minimum income required for your current living expense:
$
Would this be your sole source of income?
Do you own or rent your home?
If own
Current Value:
$
Mortgage:
$
Your total assets:
$
Total Liabilities:
$
Net worth: $
Amount of cash available for investment:
$
Do you have a financing source?
Amount of financing available $
If qualified, when would you be ready to invest in your Café?
What is your preference for your café location? (please be specific)
Will you be the sole owner of this business?
If you choose co-ownership, have the co-owners fill out a separate application:
Estimated training date, should you choose to invest?
Estimated date of opening should you be selected?
Please read and sign the following
I understand that the granting of a Flying
Saucers® License is at the sole discretion of the Licensor, Flying Saucers
Café.
I understand that the information I am
receiving from the licensor or from any employee, agent, or Licensee
of the Licensor is highly confidential, has been developed at great
expense and effort to the Licensor, is being made available to me because
of this application, and will be held in strictest confidence.
I will not divulge or use any data, customer
or employee names and addresses, techniques, methods, advertising materials,
forms, or other information of whatever kind received from the Licensor
without it's consent.
I understand that the granting of a Flying
Saucers® License is at the sole discretion of the Licensor, Flying Saucers
Café.
I understand that I will have to successfully
complete the Licensors training academy before I will be allowed to open
for business.
I authorize the procurement of an investigative
consumer report and understand that it may contain information about
my background, character, general reputation, and mode of living, credit
worthiness, and job performance. I understand that, upon written request
within a reasonable period of time, I am entitled to additional information
concerning the nature and scope of this investigation. I hereby release
Flying Saucers® Inc., Flying Saucers Café™, it's subsidiaries, their
officers, agents, employees and servants from any liability arising
from the preparation of this report or investigation relating thereto.
This authorization for release of information
includes but is lot limited to matters of opinion relating to my character,
ability, reputation and past performance. I authorize all persons, schools,
companies, corporations, credit bureaus, and law enforcement agencies
to release such information without restriction or qualification Flying
Saucers® Inc., Flying Saucers Café™, it's subsidiaries, their officers,
agents, employees and servants. I voluntarily waive all recourse and
release them from liability for complying with this authorization. This
authorization/release shall apply to this as well as any future request
for an investigative consumer report by the above named firm. I authorize
that a photocopy or facsimile of this release be considered as valid
as the original.
I have read this application and everything
I have stated in it is true. Additionally, I understand that the Licensor
will rely upon the information provided by me.
Signature (required)
___________________________________________ Date _____________
Signature (required) ___________________________________________
Date _____________
PLEASE SIGN THIS FORM AND THEN FAX TO (419) 828-3647)
