Applicant Personal Data

Applicant Name:

Date of Birth: 

Marital Status:

Home Address:        

Email Address:      

City:     State   Zip:  

Home Phone:  

Business:    Fax:

May we contact your business number?

* Co-Applicant Personal Data

Applicant Name:

Date of Birth: 

Marital Status:

Home Address:        

Email Address:      

City:     State   Zip:  

Home Phone:  

Business:    Fax:

What is your relationship to the applicant?

* How Did You First Learn About The X-Trainers’ Opportunity ?

Please Be Specific   

 * Intentions and Expectations as a X-Trainers’ Owner

After the X-Trainers’ Franchise has been awarded, will one of you continue to work at your current place of employment as listed?

Who will operate your X-Trainers’ Facility?

In what city and state/ province would you prefer to own a X-Trainers’ Facility?

How soon would you be able to operate the X-Trainers’ facility?

Do you own a franchise at this time?  

Have you ever failed in business or filed bankruptcy?  

 (if yes, please explain)  

 Are you a party to any pending lawsuits or are any law suits pending against you?

 (if yes, please explain including any remaining liabilities) 

 Have you ever been convicted of any crime?

 Are you a U.S. Citizen?

If “no”, are you authorized to lawfully work in the United States ? 

* Applicant’s Employment History (Please list your current place of employment first.)

* Co-Applicant’s Employment History (Please List your current place of employment first. Attach additional pages if necessary)

  *Funding

 It is not necessary to list husband/wife finances separately.  Please attach a current financial statement if available.

 Where will the capital come from for the start-up?      

Do you plan to have a partner (other than the co-applicant)?      

If you own your home do you plan to borrow against it?      

If “yes” what dollar amount?     

Do you plan to obtain a loan from any other source to assist you in funding this opportunity?      How much?     

 * Sources of Income

List all income to continue after this opportunity is purchased. (annual totals)

Pension/ Social Security                         

Continuing Salary                                   

Real Estate                                            

Alimony                                                 

Interest                                                   

Other (please list)                                     

TOTAL INCOME            

*Liabilities:                                      Applicant                                  Co-Applicant

Mortgages                                                                                                     

Auto loans                                                                  

Unpaid taxes                                                               

Loans due relatives                                                       

Credit card debt                                                          

Other                                                                                           

TOTAL LIABILITIES            

NET WORTH (Assets – liabilities)      

I/we certify that the information I/we have provided on this questionnaire is complete and correct.  It is understood and agreed that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or other legal remedies on behalf of X-Trainers Franchise.  I/we hereby authorize X-Trainers Franchise or its authorized agents to obtain any of the above information and I/we authorize the release of such information to X-Trainers Franchise or its authorized agents.  I hereby release from liability X-Trainers Franchise and its agents for seeking such information.

Signature of Applicant:          Date:      

Co-Applicant:               Date:       

All information is confidential