Confidential Questionaire

Personal Data
Name*
First Last
Age*
Spouse Name*
First Last
Age*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Work Phone*
Your Email*
Spouse Email*
Do you own your home?*
- Yes
- No
Are You A Veteran?*
- Yes
- No
Names and ages of children/dependents*
Enter 0 if none.
Education*
High school, college, graduate degree
Spouse Education*
High school, college, graduate degree
Hobbies*
Please list your hobbies, special interests, etc.
Employment
Current Position*
Spouse's Current Position*
Employer*
Spouse's Employer*
Duties*
Spouse's Duties*
Annual Income*
Spouse's Annual Income*
Why are you considering a change from your employment at this time?*
What have your liked MOST about your past employment?*
What have your liked LEAST about your past employment?*
Business Ownership Data
Have you or your family ever owned a business?*
- Yes
- No
If yes, please describe the business and details
How long have you been looking for a business?*
What attracts you to owning your own business?*
Are you seeking an individual franchise or multiple units?
- Individual Franchise
- Multiple units
What other businesses have you investigated?*
What are your strengths related to managing a business?*
What are your weaknesses related to managing a business?*
What are your major concerns about business ownership?*
Which types of businesses have initial appeal to you?*
Check all that apply
- Select All
- Retail
- Home Based
- Personal Services
- Mobile
- Fast Food
- Other Food
- Consumer Products
- Business To Business
Using a scale of 1 to 10 (with 10 being the highest level of interest, and 1 being the lowest), please rate your personal interest in the following areas:
Mechanical/Automotive*
Landscaping*
Beauty/Fashion*
Remodeling/Home Improvement*
Real Estate Buying or Selling*
Working with Children*
Organizing Things*
Pets & Animals*
Fitness & Sports*
Coaching or Teaching*
Having a Healthy Lifestyle*
Computer/High Tech*
Working with Hands and Tools*
Working with Numbers*
Organizing People*
Design & Decor*
Being around Cars/Motorcycles*
Entertainment or Dining or Hosting Parties*
Travel & Leisure*
Talking with Just About Anyone*
Volunteering/Getting involved in Community*
Working with Seniors*
Networking with People*
Describe how much you would enjoy the following roles
Prospecting for new customers*
- High
- Medium
- Low
Consultative selling*
- High
- Medium
- Low
Providing service quotes or estimates*
- High
- Medium
- Low
Marketing and advertising your business*
- High
- Medium
- Low
Networking with local business groups*
- High
- Medium
- Low
Being the administrator in the back office*
- High
- Medium
- Low
Hiring and firing employees*
- High
- Medium
- Low
Managing and training employees*
- High
- Medium
- Low
Accounting and bookkeeping*
- High
- Medium
- Low
What type of employee do you prefer to have in your business?*
Check top choice
- White Collar
- Blue Collar
- Skilled
- Unskilled
- Don't Care
How many employees would you prefer to have in your business?*
Check top choice
- None
- Less than 5
- 5-10
- 10 or more
- Don't Care
What skills and area of business management interests you the most?*
Check all that apply
- Daily Operations
- Selling
- Managing Employees
- General Management
- Consulting
- Marketing
- Advertising
- Finance/Bookkeeping
- Working with Customers
- Calling on Other Businesses
- Manufacturing Products
- Other
What skills and area of business management interests you the most? (Other)
If not listed above, please describe
Lifestyle Data
In what areas would you prefer to own and operate your business?*
Please list city/state
1. 2. 3.
When would you like to start your new business?
Would you be involved on a full-time or part-time basis?*
- Full Time
- Part Time
What hours of the day or week do you prefer to work?*
What do you want your role in the business to be in the early years?*
Please check top choice
- Very Active
- Full-time
- Part-time
- Passive
What do you want your role in the business to be 3-5 years later?*
Please check top choice
- Very Active
- Full-time
- Part-time
- Passive
How would you rate what other people think about your choice of business*
- High
- Medium
- Low
How would you rate being able to grow additional units/larger territory*
- High
- Medium
- Low
How would you rate making a meaningful contribution with your business*
- High
- Medium
- Low
How supportive is your family about starting a new business?*
- Excellent
- Average
- Poor
Please explain the previous*
Financial Data
Cash available for investment in a business*
If additional funds are needed to start a business, are they available to you?*
- Yes
- No
Please explain
Do you have a source of income other than salary?*
- Yes
- No
Please explain
What is your monthly household overhead?*
How will you cover your living expenses as you build the business?*
Assets
Cash (checking account)*
Savings*
Stocks, Bonds, securities*
IRA's*
401(k)'s*
Primary home*
market value
Other real estate*
market value
Autos*
market value
Money due you*
Other assets*
Describe Other Assets
Total Assets
Liabilities
Total balance of credit card debt*
Total balance of auto loans*
Total balance of student loans*
Primary home mortgage balance*
Secondary home mortgage balance*
Other real estate debt*
Home equity line of credit*
Other debts*
Describe other debts
Total Liabilities*
Net Worth
Total Assets minus total liabilities.
The following information is requested because any affirmative answers may have a direct bearing on your ability to obtain financing for starting a business. This is a critical factor in determining which companies may match with your criteria.
Have you or your spouse ever been involved in a personal or business bankruptcy?*
- Yes
- No
Have you or your spouse ever been convicted of a crime?*
- Yes
- No
Are you or your spouse currently under any type of criminal investigation?*
- Yes
- No
Are you or your spouse currently involved in any pending lawsuits?*
- Yes
- No
Are you or your spouse subject to any civil judgments?*
- Yes
- No
Please explain any affirmative answers to the previous five questions.
What else should we know to help you find the perfect business?
All of 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 compile general information and that it is in no way binding upon either party. This is not a contract.
Phone
This field is for validation purposes and should be left unchanged.

Confidential Questionaire

Personal Data

Employment

Business Ownership Data

Lifestyle Data

Financial Data

Assets

Liabilities