Senior Safe Homes Franchise Application

Home
Senior Safe Homes Franchise Application

APPLICANT INFORMATION
Name
First Last
Date of birth
SSN
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Day Phone
- Own
- Rent
How Long
No. of Dependents
Spouse Name
First Last
Evening Phone
Cell Phone
EMPLOYMENT INFORMATION
Current Employer
How Long
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position
Annual income
Previous Employer
EmployerAddress
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position
Annual Income
CORPORATE INFORMATION — IF YOUR CORPORATE STRUCTURE EXISTS
Company Name
Federal Tax I.D.#
D/B/A
Dun & Bradstreet #
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Incorporation
Years in Business
State of Incorporation
CORPORATE OFFICERS (CORPORATION ONLY)
Name
First Last
Title
% of Ownership
Name
First Last
Title
% of Ownership
Name
First Last
Title
% of Ownership
EDUCATION
High School
Years
Graduated
- Yes
- No
- GED
College/University
Years
Degree Achieved
- Yes
- No
Other
Years
Degree or Certificate
BUSINESS REFERENCES
Name
First Last
Title
Company
Phone
Name
First Last
Title
Company
Phone
PERSONAL REFERENCES
Name
First Last
Relationship
Company
Phone
Name
First Last
Relationship
Company
Phone
GENERAL INFORMATION
Are you currently subject to a non-compete agreement of any kind?
- Yes - (Explain Below)
- No
Have you even been convicted of a felony?
- Yes - (Explain Below)
- No
Are you a defendant in any law suits or legal actions?
- Yes - (Explain Below)
- No
Have you ever declared bankruptcy?
- Yes - (Explain Below)
- No
Are you a US citizen?
- Yes
- No - (Explain Below)
Nonsmoker?
- Yes
- No
DEVELOPMENT DATA
I am interested in a single location
- Yes
- No
I am interested in a multiple location
- Yes
- No
How Many?
I wish to operate my business (please “x”)
- as an owner operator
- owner investor
- with my spouse
- with partner
- with children
I plan to acquire my first location
- Within 6 months
- 7-12 months
- 13-18 months
- unsure
Please list your geographic interest
First choice Second choice Third choice
How did you hear about Baby Safe Homes?
Who will be responsible for the daily operations of your business? (Name)
Please list operator’s experience below
Company Position No. of Years
Company Position No. of Years
Company Position No. of Years
Are you currently involved with any childcare related franchise(s)
- Yes
- No
If yes, please list company and position below
Company Position No. of Years
Company Position No. of Years
Company Position No. of Years
Have you ever owned a franchised business?
- Yes - (Explain Below)
- No
Have you ever owned a similar business or other hands-on related experience?
- Yes - (Explain Below)
- No

Senior Safe Homes Franchise Application

APPLICANT INFORMATION

EMPLOYMENT INFORMATION

CORPORATE INFORMATION — IF YOUR CORPORATE STRUCTURE EXISTS

CORPORATE OFFICERS (CORPORATION ONLY)

EDUCATION

BUSINESS REFERENCES

PERSONAL REFERENCES

GENERAL INFORMATION

DEVELOPMENT DATA