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* Today's Date:
* Name (First, Middle, Last)
* Address
* City
* State
* ZipCode
* Social Securty Number xxx-xx-xxxx
* Your Email Address
* Home Phone xxx-xxx-xxxx
Fax Phone xxx-xxx-xxxx
Work Phone xxx-xxx-xxxx
* Date of Birth
Name of Spouse:
Number of Dependents:
Age of Dependents:
List Former Addresses for the Past Five Years:
* Education Status: Graduate Degree Undergraduate Degree High School Senior
Degrees Obtained:
College or University (City/State):
Major Subjects:
Dates of Employment From:
To:
Employer Name:
Employer Address:
Employer Telephone:
Type of Business:
Current Job Title:
Describe Your Duties and Responsibilities (Max 200 words):
Will you continue this position if a franchise is granted?
No
Yes
May we contact your present employer?
Geographical Area of Interest:
Have you ever filed for bankruptcy?
If yes, when and why did you file:
Have you ever been convicted of a crime?
If yes, explain in detail:
Have you ever been party to a law suit or other legal action?
If you were granted a franchise, when would you be able to begin this venture?
Do you have any experience in owning a business?
What is the best time to contact you?
What percentage of time do you plan on dedicating to franchise development?
Describe the experience(s) you have had that you believe will enable you to be successful as a ClubScientific franchisee:
* 1st Name:
* 1st Address
* 1st City
* 1st State
* 1st ZipCode
* 2nd Name:
* 2nd Address
* 2nd City
* 2nd State
* 2nd ZipCode
* 3rd Name:
* 3rd Address
* 3rd City
* 3rd State
* 3rd ZipCode
What three adjectives best describe your personality?
What distinguishes you from other people?
What do your peers, co-worders and family most admire about you?
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