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BULLET PERSONAL DATA

Name Date
Home Address City State Zip
Home Phone Cell Phone Email
Business Phone Fax Pager
Date of Birth Place of Birth Marital Status
Spouse's Name Spouse's Occupation How Long?
Child's Name Age Child's Name Age
Previous Address City State Zip
Are you a U.S. Citizen Yes No If not, what Country?

BULLET EDUCATION

Name of High School Years Completed
Name of College Degree
Name of College Degree

Describe any training in sales, management, or retail:

BULLET EMPLOYMENT HISTORY FOR LAST 10 YEARS (beginning with the most recent)

Company Name From To
May we contact this employer Yes No Contact Name Phone
Address City State Zip
Type of Business # of Employees Supervised  
Describe Responsibilities:
Company Name From To
May we contact this employer Yes No Contact Name Phone
Address City State Zip
Type of Business # of Employees Supervised  
Describe Responsibilities:

BULLET PERSONAL FINANCIAL STATEMENT

ASSETS

  

LIABILITIES

  
Cash on hand and in banks $ Notes payable to banks - secured and unsecured $
U.S. government securities $ Notes, loans, advances, accounts payable $
Trade accounts and loans receivable $ Credit card debt $
Notes receivable - secured and unsecured $ Loan against life insurance $
Life insurance - cash surrender value $ Property taxes and assessments payable $
Stocks and bonds - Marketable and not $ Mortgages payable on real estate $
Real Estate $ Liens on real estate $
Automobiles - market value $ Federal and state taxes on current income $
Other assets, property, or investments (itemize below)   Other debts (itemize below)  
$ $
$ $
$ $
$ $
       
TOTAL ASSETS $ TOTAL LIABILITIES $
       

ANNUAL SOURCES OF INCOME

NET WORTH

  
Salary $ Total assets $
Bonus and commissions $ Less total liabilities $
Dividends and interest $ NET WORTH $
Real estate income $    
Business profession income $    
Other income (itemize below)      
  $    
  $    
  $    

BULLET BUSINESS REFERENCES (provide at least three)

Name Phone
Home Address City State Zip
Name Phone
Home Address City State Zip
Name Phone
Home Address City State Zip

BULLET BUSINESS DATA

How did you learn about the Smiling Moose Deli franchise program?
Do you now operate or have you had experience in operating a restaurant?
If yes, explain:
 Yes No

Do you intend to devote yourself full-time to the day-to-day operation of a Smiling Moose Deli franchise?
If not, provide explanation and details how you will oversee the business:

 Yes No

Have you (and, if applicable, partners, officers, directors or shareholders) been subject to or convicted of any administrative, criminal or civil action or offense?
If yes, explain:

 Yes No
Have you (and, if applicable, partners, officers, directors or shareholders) ever been adjudged bankrupt or reorganized due to insolvency, or been a principle officer of any company or a partner in any partnership that was adjudged bankrupt or reorganized due to insolvency?
If yes, explain:
 Yes No
Will your franchise investment come from your own capital? Yes No
Are you willing to relocate? Yes No
Geographic location preference? Yes No

First Choice
Second Choice
Third Choice

 
What date do you plan to open your first Smiling Moose Deli?  

BULLET AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I hereby attest to the accuracy of the information contained in this confidential Smiling Moose Deli application. I authorize Smiling Moose Deli or its agents to verify the data submitted, to obtain a consumer credit report and to make such additional credit, background, criminal
or character confirmation which it deems necessary or advisable.

In connection with these financial and background investigations, I authorize Smiling Moose Deli, Inc. or its agents to contact present or past employers, schools, financial institutions, law enforcement agencies and any other person, firm corporation or source. I authorize any such source to provide Smiling Moose Deli, Inc. or its agents all information concerning me, and I hereby release any such source and its agents and employees from all liability for providing this information. I understand such reports may contain information concerning my education, employment, work habits, character or skill, criminal and credit history.

I authorize that any photocopy or facsimile of this document may be accepted with the same authority as the original. THIS COPY WILL NEED TO BE REWRITTEN FOR ELECTRONIC DISTRIBUTION.

Smiling Moose Deli agrees to maintain in a confidential manner and restrict the use of any information contained or obtained in connection with this application for a Smiling Moose Deli franchise. I authorize Smiling Moose Deli, Inc. to release to prospective financing sources any information concerning me that may be requested by them.

By checking this box, I certify that the above statements are accurate. THIS COPY WILL NEED TO BE REVIEWED BY AN ATTORNEY.