Confidential Questionaire Personal DataName* First Last Age* Spouse Name First Last Age* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell 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 degreeSpouse EducationHigh school, college, graduate degreeHobbies*Please list your hobbies, special interests, etc.EmploymentCurrent Position* Spouse's Current Position Employer* Spouse's Employer Duties* Spouse's Duties Annual Income*Spouse's Annual IncomeWhy 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 DataHave you or your family ever owned a business?* Yes No If yes, please describe the business and detailsHow 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*12345678910Landscaping*12345678910Beauty/Fashion*12345678910Remodeling/Home Improvement*12345678910Real Estate Buying or Selling*12345678910Working with Children*12345678910Organizing Things*12345678910Pets & Animals*12345678910Fitness & Sports*12345678910Coaching or Teaching*12345678910Having a Healthy Lifestyle*12345678910Computer/High Tech*12345678910Working with Hands and Tools*12345678910Working with Numbers*12345678910Organizing People*12345678910Design & Decor*12345678910Being around Cars/Motorcycles*12345678919Entertainment or Dining or Hosting Parties*12345678910Travel & Leisure*12345678910Talking with Just About Anyone*12345678910Volunteering/Getting involved in Community*12345678910Working with Seniors*12345678910Networking with People*12345678910Describe how much you would enjoy the following rolesProspecting 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 DataIn what areas would you prefer to own and operate your business?*Please list city/state1.2.3. 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 DataCash available for investment in a business*If additional funds are needed to start a business, are they available to you?* Yes No Please explainDo you have a source of income other than salary?* Yes No Please explainWhat is your monthly household overhead?* How will you cover your living expenses as you build the business?* AssetsCash (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 AssetsTotal AssetsLiabilitiesTotal 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 debtsTotal Liabilities*Net WorthTotal 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.NameThis field is for validation purposes and should be left unchanged. Δ