PERSONAL DATA:
Name:
Address:
City:
Check One:
E-Mail:
Retype E-Mail:
Home Phone:
Cell Phone:
Work Phone:
Best Number To Call:
Date of Birth:
Describe your time frame for investigating and opening a business:
Tell us about who else will be involved as an owner, investor or operator:
What is attracting you to explore the Senior Financial Franchise Opportunity?:
Help us to understand more about you and your interests. Specifically, please tell us about
What else would you like to share with us?:
CAREER DATA:
Current or Most Recent Employment:
Company:
Position/Title:
Duties:
Work Dates: Start:
Previous Employment:
Company:
Position/Title:
Duties:
Work Dates: Start:
Years of Experience in the Financial Industry:
Describe your Background and Experience in the Financial Industry:
Do You Have Prior Business Ownership Experience?:
If you answered "Yes", please describe your Prior Business Ownership Experience:
Do You See Clients In Your Office?:
Licenses Held:
Other Certifications or Designations:
Are You A Broker Dealer?:
If you answered "Yes", please describe the Products you Currently Offer:
Describe The Type of Marketing You Do:
Primary Target
Seniors 60+
2008 or Latest
Describe In Detail Your Education [Degrees, GPA, Institutions, etc.]:
What else should we know about your Career, Education or License background?:
FRANCHISE LOCATION PREFERENCES (City, State, Zip):
Frist Choice:
Second Choice:
Third Choice:
CONFIDENTIAL FINANCIAL STATEMENT:
Additional Income & Funding (Rentals, Investments, etc.), Include Source and Annual Amount:
SSN:
Credit Rating:
If you answered "Below Average", please explain:
Have you or your spouse ever been involved in a personal or business bankruptcy?
Have you or your spouse ever been convicted of a crime?:
Are you or your spouse under any type of criminal investigation?:
Are you or your spouse currently involved in any pending lawsuits?:
Are you or your spouse subject to any civil judgments?:
If you answered "Yes", to any of the five questions above, please explain:
To the best of my knowledge all information above is accurate.This box MUST be checked for this form to be submitted.
Then, click on the SUBMIT button once.
