Contact Name First* Last* Spouse/Partner Name First Last Address(required) Street Address * Address Line 2 City* State / Province /Region Postal / Zip Code * Country* How long have you lived at this address? Cell Number Other Number Email * Spouse/Partner Email Citizenship Status Dependents List all dependents as represented on your tax filings Name First Last Age Name First Last Age Name First Last Age Upload Resume/CV (Optional) Upload Photo (Optional) Business Background Tell us a little about your business experience Present Employer Title Responsibilities Length of Employment Annual Salary Will you be leaving this employment to open your business? Any other source of income? Total Combined Income Have you ever owned your own business? What type of business? How long operated How did you become interested in this business? * Have you ever managed employees If so, at what capacity? When would you like open? * Whats your primary reason(s) for going into your own business? * What would you consider your strengths in owning your own business? What would you consider your primary concerns in owning your own business? * In which geographical area would you like to open your business? * Will you be opening this business with a partner? If so, will this partner be active? What languages do you speak? Financial Information Assets: Basic financial asset information Cash on Hand & In Banks Stocks, Bonds & Securities Retirement Funds Loans owed to you (Due w/in 1 yr) Do You Own or Rent Your Home? Real Estate: (present value) Businesses Owned Any other assets Liabilities: Basic liability infomation Notes payable to bank Notes payable to individuals Total credit card debt Vehicle Loans Home Mortgage Other Mortgage Student Loans Any other debts Net Worth: Assets minus Liabilities Total Assets Total Liabilities Assets - Liabilities = Net Worth Amount of Capital to Invest * Source of Capital * Closing This is not a contractual agreement. The completion of this document does not obligate you in any way to purchase a Lice Lifters Franchise. The undersigned certifies that the information supplied is true and correct.