Just-A-Buck

Please fill out our secure franchise application form:

Your Name

(Prefix)

(First Name)

(M.I.)

(Last Name)

Personal Data

Address

City / State / Zip
Home Phone
Business Phone
Fax
E-Mail Address
Social Security #
Date of Birth
Spouse's Name
# of Dependents

Business Experience

From	To	Firm	Position	Annual Income

Exact nature of business experience including self employment:

Have you ever failed in business or compromised with creditors?

Yes No

If yes, when, where, circumstances (including any remaining liabilities):

Are there any lawsuits pending against you?

Yes No

If yes, please give particulars:

Education

High School Some College 4 Years/Graduate

Financial Data

Cash
Readily Negotiable Securities
Fair Market Value of Real Estate Above Mortgages
Liquid Equity in Business Ventures
Other
Total Assets
Liabilities Other Than Mortgages Deducted Above
Total Liability
Net Worth

Please describe assets from above:

Personal Bank Reference
Business Bank Reference

Will a family member or anyone else be active in this business with you?

Yes No

Where and When

When would you be able to start this venture?
Are you prepared to devote full time to this business?	Yes No
Territory in which you are interested?

Would you accept an alternate territory if your first choice is not available?

Yes No

How did you hear about the Just-A-Buck franchise? (please be specific)

Comments

Please use this space to tell us anything else which you think is relevant, such as family business history, your personal business objectives, tax considerations, business ventures in which you have participated.

I hearby give Just-A-Buck Licensing, Inc. and their duly authorized representatives permission to check the above references and to make a credit check with the credit bureau in any county or municipality where I have lived or worked or where they feel such a check is necessary.

Agree Disagree

Thanks again for spending time on site with Just-A-Buck.
Here's hoping the bucks start here!

Tel: 845-561-7411
Fax: 845-561-7433