Tell us about yourself... (All information is confidential and secure)

Instructions:
Required fields are marked by an *.
To ensure accurate processing, please do not use symbols (such as ">& - / #) in your address.
Prefix:
First Name: *
Last Name: *
Email Address: *
Home Address: *
City: *
State (Abbreviation) / County: *
ZIP / Postal Code: *
Phone: *
Convenient Time to Call: *

F A M I L Y
Birth Place:
Date of Birth: *
Citizenship:
Marital Status:
Spouse's Name  
Health:
This is a construction franchise. Would you have any physical limitations or major illnesses which might restrict your activities?  No      Yes
Education: *


B U S I N E S S   O R   S E L F   E M P L O Y M E N T   H I S T O R Y
Company Name:
Date Started:
Date Left:
Brief description of responsibility and hours worked daily
Final annual compensation:
Reason for leaving:


F I N A N C I A L
Total LIQUID ASSETS ( cash, stocks, bonds etc.) *
Do you own your home? *
Approximate Market Value:
Mortgage Balance:
Other Assets (cars, other real estate, personal property) *
Other Debt (credit cards, car loans, etc.) *
Total Net worth (assets minus debt) *
Approximate Net Worth: *


Do you plan to operate business self		 *
How many hours per week will you devote to the business? *
List territory preferences in order: *

I acknowledge that the above information about me is truthful and accurate as of this date. I also consent to Archadeck (U.S. Structures, Inc.) or its agents collecting and retaining such information for the purpose of evaluating me as a prospective franchisee.

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