The Business Factory

You have taken the first step to building your business and your dreams!

The Business Factory would like to know more about you and what assets you have available to build your business. We will analyze your information and help build a long term strategy to help you meet your goals. Please take your time filling out this information questionnaire. We will contact you shortly to discuss your answers, talk about some of the franchise types that would be a great fit for what interests you and what you have expertise in.

We look forward to building an ever-lasting relationship with you and making your financial dreams come true for yourself, your family and your future!

Date

Applicant Name

Spouse Name

Partner Name (if applicable)

Street Address

City

State / Province / Region

Postal / Zip Code

Home Phone

Cell Phone

Business Phone

Fax Number

Date of Birth

Work Experience (Time Frame, Positions, Responsibilities)

Education Level

Some High School

High School Graduate

Some College

College Graduate

Masters Degree

Where are you currently employed? *

What is your job title? *

Do you have business management or business ownership experience? *

Yes

If yes, explain.

Rate your knowledge of franchising in general: *

None

Weak

Average

Strong

Very Strong

What industries are you interested in and why? *

What businesses have you looked at? *

What are your biggest concerns, fears or reservations about becoming a business owner? *

Please tell us how you plan to pay for your business including working capital? *

Cash on Hand

Savings

Stocks

Home Equity

Family/Friends

Commercial Bank Loan

Partner

Sale of Property

SBA Loan

401K

Other

If Other, explain:

Is your credit score above 650?

Yes

No

Unknown

Estimated Credit Score

Have you ever declared bankruptcy?

Yes

If yes, what month and year was it discharged? MM-YYYY

If yes, what Chapter?

7
11
13
Medical

Any notes about bankruptcy?

What do you estimate the amount of monthly income to pay your current living expenses?

Personal Financial Statements

Annual Salary (W2, box 3)

Spouse Annual Salary

Combined Annual Salary

2006 Annual Income Reported to IRS

2005 Annual Income Reported to IRS

2004 Annual Income Reported to IRS *

2006 1099 (If Any)

2005 1099 (If Any)

2004 1099 (If Any)

Will income continue after franchise is open?

Yes

If not, how much income will continue? $

Do you have tax exempt income?

Yes

If yes:

Housing Allowance	$
Hazardous Pay	$
Child Support	$
Alimony	$
Other	$

Assets

Cash in Banks	$
Cash in Savings	$
Stocks and Bonds	$
IRA and 401k	$
Money Due by Others	$
Cash Surrender Value Life Insurance	$
Real Estate (Residence)	$
Real Estate (Others)	$
Automobiles	$
Vehicles Other	$
Collectibles	$
Other Assets	$
Total Assets	$

Liabilities

	Payable	Monthly Payments
Notes Payable to Banks	$	$
Notes Payable Other	$	$
Charge Accounts	$	$
Credit Cards	$	$
Finance Companies	$	$
Due on Life Insurance	$	$
Mortgage Residence	$	$
Mortgage Other	$	$
Due on Automobiles	$	$
Due on Other Vehicles	$	$
Taxes Payable	$	$
Other Liabilities	$	$
Total Liabilities	$	$

Net Worth (Assets-Liabilities)

What do you want The Business Factory to know about your business goals, preferences, strategies or personal information about this and future projects come together?