Personal Information
* First Name:
* Last Name:
* Address 1:
* City:
* State:
* Postal Code:
* Phone:
Work Phone:
* Cell Phone:
* Best Time to Call:
* Email Address:
* Citizenship:
Married:
Spouses Name:
Children:
Ages:
* Have you ever been convicted of anything other than minor traffic violation?
* Have any judgements been entered against you or a business you controlled or did control?
Education
* Please check the highest grade completed.
Business Consideration
* Have you ever owned a business?
* Type of Business:
* When are you available for an interview at our Corporate Office?
Financial Data - Assets
Liquid (cash, unrestricted securities)
* Restricted securities (IRA, 401K 9 (s), ect)
* Do you rent or own?
Home Value (and other Real Estate)
* Other assets (auto, business, receivables, ect)
* Total Assets
Financial Data - Liabilities
Mortgages (all debt on all real estate)
* Other Liabilities (auto loan, credit care, ect)
* Total Liabilities
Financial Data - Net Worth
* Total Assets Less Total Liabilities
* Have you ever declared personal or business bankruptcy?
Partner Information
* Will you have any business partners?
Partner Name
Partner Name
What involvement will they have?
General Information
* How did you hear about SarahCare?
* Based on the answer you selected for How did you hear about SarahCare? Please enter the details in the space below (Ex: Which SarahCare Location, What Ad Agency, Web Search Engine or Who referred you?)
Comments:
By checking this box below you certify that, the statements are true and accurate.
I hereby certify that to the best of my knowledge,information, and belief, the above statements are true and accurate. Should I continue pursuing Sarah® Adult Day Services, Inc. Franchise, I shall provide additional and more complete information to Sarah® Adult Day Services, Inc., as requested. Receipt, completion or submittal of this Preliminary Franchise Application is not intended to be construed as an offer to franchise. Offered by prospectus only.
* indicates required response