Fields marked with * are mandatory.

Personal Information

*First Name: *Last Name: Middle Name:
Gender: Address: How many years at this address?
Male Female
*City: *State / Province: *Zip / Postal Code:
*Country: Birth Date: Phone:
Best Time To Contact: *Email: Marital Status:
Single Married


Present Employer: Title: Date Started:

Previous Employment

Employer Name

Job Title

Date From

Date To


Business Operation Plan

Who will be responsible for the daily operation of your store? Do you expect to have a partner? If yes, business partner's name:
Yes No
Would this business be your only source of income?    
Yes No    

Personal Qualification Questions

Are you a U.S. Citizen or do you have a permanent U.S. Visa (green card): Have you ever been convicted of a felony? Have you ever filed for bankruptcy?
Yes No Yes No Yes No

Financial Qualifications

Non-borrowed Cash available to invest in business ($):  



Cash in Bank ($): Mortgages ($):
Stocks and marketable securities ($): Credit card balances ($):
Retirement plan funds ($): Auto loans ($):
Value of real estate ($):  
Other Assets ($): Other debt ($):

Total Assets:

Total Liabilities:

Total Net Worth (Total Assets minus Total Liabilities ):