Franchise Application

Personal Information

this information is kept confidential

First Name (Required)

Last Name (Required)

Your E-Mail Address (Required)

Address (Required)

City (Required)

State (Required)

Zip Code (Required)

Primary Phone Number (Required)

Secondary Phone Number

Fax Number

Best Time To Call

you can select more than one option

Morning

Afternoon

Evening

I am an American Citizen

Education

Marital Status (Required)

Single
Married
Divorced

Spouse's Name

How Did You Hear About Us?

Present Employment

Job Description

Present Income

1st Location Choice (Required)

City / State

2nd Location Choice

City / State

Assets

Cash in Checking Account

Cash In Savings Account

Stocks / Bonds

IRA Accounts

401k's

Real Estate (home)

value

Real Estate (other)

value

Automobiles

Business Value

if you are a business owner

Total Assets

Liabilities

Mortgage (home)

Mortgage (other)

Notes to Banks

Other Notes Due

Credit Cards

Taxes Due

Auto's Due

All Other Liabilities

Total Liabilities

Investment Information

Your Net Worth

take total assets minus total liabilities

Your Total Liquid Capital to Invest in Your Business

Your ability to finance the balance of your business. How Much?

Total Investment

Do you have any other source of investment capital?

All the information stated herein is a true and correct representation of my personal and financial condition. It is understood that the purpose of this questionnaire is to gather basic information and that it is in no way binding upon Rejuvenate Health and Fitness. THIS IS NOT A CONTRACT

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Franchise Application