Application for Additional Information

The filing of this form does not obligate the applicant to purchase or the franchisor to sell a franchise. Complete in full and do not use abbreviations. Please print clearly or type.

Note: Fields denoted with a * are mandatory.
 
 
Your Personal Information
  * First Name           * Last Name          Middle Initial 
  * Citizen of 
  * Date of Birth   
  * Tax ID/Social Security Number       
  * Gender       Other names known by 
  * Are you of legal age in your State/Province/Residence Area ?
  * Have you ever been convicted of a felony ?   
  * Have you ever been associated directly or indirectly with terrorist activities ?  
  * Have you been involved in any litigation proceeding within the last 5 years ?     
     (If yes, additional information will be required at the time of sale)
  * Telephone (Home)    (Fax)     (Mobile)    
(area code/country & city code) (area code/country & city code) (area code/country & city code)
  * Residence Address       

*  Suite/Apartment # 

  * City             * State/Province              
  * Zip/Postal Code             * Country 
  * Email Address       
 
Spouse Personal Information  (Use A Separate Application for Partners)
 
   First Name     Last Name      Middle Initial 
   Citizen of 
  
   Date of Birth     
 
   Tax ID/Social Security Number    
   Gender           Other names known by   
   Are you of legal age in your State/Province/Residence Area ? 
   Have you ever been convicted of a felony ?   
   Have you ever been associated directly or indirectly with terrorist activities ?   
   Have you been involved in any litigation proceeding within the last 5 years ?      
   (If yes, additional information will be required at the time of sale)
Educational Background
  * Highest Education Achieved   
 
Schools Attended Years Grade or Degree Attained
  *     *     *  
Business Information  (Complete All Questions)
 
  *  
  * No. Years              * Nature of Business 
Title 
Describe Position 
  * Street Address/P.O. Box 
Suite/Apartment # 
  * City         * State/Province 
  * Zip/Postal Code        * Country
  *
Telephone (Bus.)     Telephone (Alt.) 
  (area code/country & city code)      (area code/country & city code)
  * Select Your Business Experience Level 
  * May we contact you at work ?     
 
Financial Information  (Please List Figures in US Dollars)
 
  *   Income from current occupation   /year  
Income from other sources /year  
Please explain other income  
 
Personal Bank(s) Branch Address
     
 
  * Individual Liquid Assets (Cash, Stocks, etc.)  a)  
  * Individual Fixed Assets (Home, Car, etc.)  b)  
  * Individual Total Assets  (a+b) c)  
  * Individual Liabilities (Mortgages, Loans, etc.)  d)  
  * Your Individual Total Net Worth  (c-d) e)  
      (Excluding any financing listed below.)

 
  * Would this business be your sole income source ?
  * Is there other financing not included in (e) above ?
     If yes, how much financing is available ? 
 
References  (Excluding Relatives)
 
 
Name Address Telephone (area code/country & city code)
  *     *     *  
Partners  (All partners should fill out a separate Application)
 
 
  * Will you have partner(s) ?   If not, you may skip this section. Otherwise please complete all relevant sections below.

* 

 % Ownership
       
First Name Last Name Middle Initial    
       
First Name Last Name Middle Initial    
       
First Name Last Name Middle Initial    
       
First Name Last Name Middle Initial    
To include a partner's financial information, ensure they complete a separate Application for Additional Information
 
Operations
 
 
  * If qualified, when will you invest in a franchise ?       
  * How involved will you be in operating the store ?       
 
     Preferred Geographic Franchise Area
     1st Pref.   
     2nd Pref. 
  * Estimated training date should you choose to invest:   
 
Disclaimer
 
 
I authorize CPR-Cell Phone Repair Franchise Systems, Inc. and its affiliates (collectively “CPR”) to rely on the information contained in this application and any supplemental information I might later provide in deciding whether to grant me a franchise. I certify that the information contained herein is true, correct and complete as of the date shown below. I authorize CPR to conduct its own background and credit history checks using whatever resources it may be entitled under applicable law to use. I authorize CPR to start an investigative consumer report (including information as to my character, general reputation, personal characteristics and mode of living) and a credit investigation (including obtaining my credit report from CPR’s choice of credit reporting agencies). In accordance with the Privacy Act, Freedom of Information Act, Fair Credit Reporting Act and any similar federal, state or local law or regulation, I expressly authorize any past or present employer, law enforcement agency, credit reporting agency, collection agency, bank, brokerage and other financial institution, educational institution, creditor and supplier, and any other person who has knowledge of my character, work, business and educational experience, financial condition, criminal records or other information about me (whether or not contained in this application) to release information to and cooperate with CPR in conducting such investigation. I release all persons from liability as a result of their release of true and accurate information in connection with CPR’s investigation. I authorize the use of photocopied or faxed copies of my signature to obtain information in connection with CPR’s review and investigation of my application. I understand that I have a right to request that CPR disclose to me the nature and scope of its investigation and that, if my application is rejected because of information obtained from a consumer reporting agency, I might be entitled under the Fair Credit Reporting Act to the name of the agency or source of information. If I intend to own the CPR® franchise with other applicants whom I have identified to CPR, I authorize CPR to discuss with such co-applicants any information (including any derogatory credit items) that might negatively affect its determination to grant the franchise.

I am aware of no facts, circumstances or events (actual or threatened) that I have not disclosed that might make the information contained herein or that I have otherwise provided to CPR incorrect, incomplete or misleading. I agree to promptly notify CPR of any material change in any of such information and of any events that might have a material impact on the truth, accuracy or completeness of such information.


During the process of considering whether to grant me a franchise, CPR might (at its discretion) provide or grant me access to certain information, and I might receive certain information from other CPR franchisees, whether orally, in writing, or in electronic or other form or format, regarding CPR’s business and the operation of CPR stores, including, without limitation, development and operating procedures and techniques, financial information, product offerings and formulations, supply sources, actual and proposed advertising and marketing plans and techniques, development plans and processes, design and specifications (collectively, the “Information”). I agree that I will hold all Information in strict confidence, that I will not disclose any Information to any third party without CPR’s prior written consent (except to my legal and financial advisors whose duties justify the need to know such Information), and that I will use the Information only in connection with my exploration of whether to purchase a CPR franchise. I agree that I will return or destroy any Information in my possession at CPR’s direction.


 
Signatures     * I have read the above disclaimer.
 
     Type name to indicate consent. Signature required at time of sale.
   
 
  * Applicant's Typed Name      
     Date: 2/6/2008		 Spouse's Typed Name
Date: 2/6/2008
 

* 

It is recommended that you print a copy of this application for your records before clicking the "Submit" button.

  
Application © 2008 CPR
© 2008 CPR