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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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?*YesNoAre You A Veteran?*YesNoNames 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 PositionEmployer*Spouse's EmployerDuties*Spouse's DutiesAnnual 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 FranchiseMultiple unitsWhat 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*HighMediumLowConsultative selling*HighMediumLowProviding service quotes or estimates*HighMediumLowMarketing and advertising your business*HighMediumLowNetworking with local business groups*HighMediumLowBeing the administrator in the back office*HighMediumLowHiring and firing employees*HighMediumLowManaging and training employees*HighMediumLowAccounting and bookkeeping*HighMediumLowWhat type of employee do you prefer to have in your business?*Check top choiceWhite CollarBlue CollarSkilledUnskilledDon't CareHow many employees would you prefer to have in your business?*Check top choiceNoneLess than 55-1010 or moreDon't CareWhat 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 describeLifestyle 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 TimePart TimeWhat 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 ActiveFull-timePart-timePassiveWhat do you want your role in the business to be 3-5 years later?*Please check top choice Very ActiveFull-timePart-timePassiveHow would you rate what other people think about your choice of business*HighMediumLowHow would you rate being able to grow additional units/larger territory*HighMediumLowHow would you rate making a meaningful contribution with your business*HighMediumLowHow supportive is your family about starting a new business?*ExcellentAveragePoorPlease 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?*YesNoPlease explainDo you have a source of income other than salary?*YesNoPlease 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?*YesNoHave you or your spouse ever been convicted of a crime?*YesNoAre you or your spouse currently under any type of criminal investigation?*YesNoAre you or your spouse currently involved in any pending lawsuits?*YesNoAre you or your spouse subject to any civil judgments?*YesNoPlease 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.CommentsThis field is for validation purposes and should be left unchanged.