Your Personal Information
*First Name:   *Last Name:
*E-Mail:
Birthdate:
Spouse's Personal Information
First Name:      Last Name:
Birthdate:
Your Contact Information:
*Day Phone:  --
*Evening Phone:  --
Cell Phone:  --
*Best time to call:  
*Address:  
*City:  
*State:   *Zip Code:
Family Status: Single Separated Married Divorced
Highest level of education completed High School
College/University
Business/Technical
Other:
Spouse - Highest level of education completed: High School
College/University
Business/Technical
Other: 
*How did you hear
 about us?		  
Have you ever owned your own business? Yes No
If “yes”, please provide details:
How long have you been looking to buy a business?
What other ones have you considered?
Preferred territory location(s):
1st choice
2st choice
3st choice
What is your time frame for starting a business? 30 days
60 days
90 days
6 months
1 year or longer
Who do you anticipate will run your United Check center? Self/Spouse
Co-Applicant
Other:
Applicant
Current Employer/Position:
City/State:
Annual Salary: $
Applicant's Dates Employed(mm/dd/yyyy): From: To:
Attach resume if available:
(Allowed extentions:.pdf .doc, Maximum size is 0.5 Mb)

Spouse
Current Employer/Position:
City/State:
Annual Salary: $
Spouse's Dates Employed(mm/dd/yyyy): From: To:
Financial Information:
What is the minimum annual income you need to maintain your family during the first years of a new franchised business?
Do you plan to have a partner? Yes No
Do you plan to have investors? Yes No
Do you own your home? Yes No
*Source of financing:
Do you plan on using 401(k) funds or other retirement funds to finance your business? Yes No
Has any legal action been filed against you in the last three years?** Yes No
Have you ever filed for bankruptcy?** Yes No
Have you ever been convicted of a felony?** Yes No
Explanation of any “**Yes” answers
Do you have any other sources of income? Yes No
Please note source and amount per year:
Financial Data (Assets):
*Cash(Savings,Checking,Other): $
*Marketable Stocks & Bonds: $
*Real Estate Owned: $
*Other Assets (Explain): $
Financial Data (Liabilities):
*Credit Card Accounts: $
*Loans Payable: $
*Real Estate Mortgages: $
*Other Liabilities (Explain): $

PLEASE READ AND ACKNOWLEDGE

I/we understand that the purpose of this questionnaire is for information only, and is no way binding upon United Financial Services Group, Inc. or the applicants. I/we represent and warrant that the information supplied herein is complete and accurate to the best of my/our knowledge and understand that United Financial Services Group, Inc. relies on the information provided in assessing the desirability and qualifications of applicants and, further, that additional financial information may be required upon request by United Financial Services Group, Inc. I/we authorize United Financial Services Group, Inc. and its representatives to make inquiries it considers necessary and appropriate, including employment history checks, credit checks, credit reporting agencies, credit references and other sources disclosed to confirm information given.



*By: *Date:

By typing your initials and date in the above boxes you are acknowledging that you have read all information on this form in its entirety.