Franchise Program
Franchise Evaluation

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  Franchise Evaluation Form
 
Last Name First Name Middle Name / Initial
Mailing Address
City State/Province Country
Home Phone Work Phone Zip Code
Fax Number ) E-mail Address  
 
Residences (Past Three Years)
Address City State Country From Date To Date
 
Military Branch Highest Rank
Discharge Date Type of Discharge
Additional Training, Citations, Awards
 
Education
  Attendance Dates Degrees Institution
High School
College
Additional Education
 
Social Security Number United States Citizen?
Yes No
 
Additional  Information
Have you ever been convicted of a crime ?
Yes         If yes, please give details
Have you ever been involved in bankruptcy or taken advantage of insolvency laws?
Yes         If yes, please state when, where, and circumstances.
Have you ever been refused a bond?
Yes          If yes, state reason.
Are you a defendant in any suits or legal actions?
Yes          If yes, explain.
 
 
Organizations (Business, Civic, Professional)
Organizations Elected or Appointed Office
 
 
 
 
Financial
Assets     Liabilities  
Cash in Banks Notes Payable to Banks
Accounts and Notes Receivable   Open or Revolving Accounts
Stocks and Bonds   Installment Loans
Profit Share Plan Vested   Taxes Owing
Cash Value of Life Insurance   Owing against Life Insurance
Real Estate Owned   Mortgages Owed
Automobiles and Equipment   Other Liabilities
Personal Property      
Other Assets      
Total Assets   Total Liabilities
Net Worth (Assets-Liabilities)
 
Total Income (Principal & Spouse) For Last 6 Years.
Year Income($)   Year Income($)  
2007   2004  
2006   2003  
2005   2002  
 
Business and Employment Background    
1. Current or latest position From To
Company Name Telephone
Company Address    
City Postal Code
State/Province Country
Report To Job Title  
Duties
Salary: Starting Salary: Ending
 
2. Next Previous Position From To
Company Name Telephone
Company Address    
City Postal Code
State/Province Country
Report To Job Title  
Duties
Salary: Starting Salary: Ending
 
3. Next Previous Position From To
Company Name Telephone
Company Address    
City Postal Code
State/Province Country
Report To Job Title  
Duties
Salary: Starting Salary: Ending
 
4. Next Previous Position From To
Company Name Telephone
Company Address    
City Postal Code
State/Province Country
Report To Job Title  
Duties
Salary: Starting Salary: Ending
Other Employment That Might Relate To Owning Or Operating A Business.
 
References
 
Business
 
Name Relationship Years Known
Address City Phone
State/Province Country
 
 
Name Relationship Years Known
Address City Phone
State/Province Country
 
 
Name Relationship Years Known
Address City Phone
State/Province Country
 
 
Personal
 
Name Relationship Years Known
Address City Phone
State/Province Country
 
 
Name Relationship Years Known
Address City Phone
State/Province Country
 
 
Name Relationship Years Known
Address City Phone
State/Province Country
 
 
 
Additional Information
Geographical Preferences
1. 
 
2. 
 
3. 
 
If approved, how soon could you begin training?
 
How did you hear about Horizons HRS, Ltd?
 

This application does not obligate either party as a result of its submission.
I give permission to Horizons HRS, Ltd. to contact any of the above mentioned to verify the statements given. I understand that any false statement is sufficient cause for rejection of my application with Horizons HRS, Ltd.  I certify that all statements contained in this application are true and I agree with and accept this statement.