Personal Information
Date :
Name :
Date of Birth :
SSN :
Home address :
City :
State :
Zip :
Home Phone :
Work Phone :
Cell Phone :
E Mail :
Best place to call :
Home
Work
Cell
Best time to call :
AM
PM
Marital Status :
Married
Single
Divorced
If married will your spouse participate in the business :
Yes
No
Spouse's name :
Date of birth :
SSN :
Residence :
Own
Rent
How Long? :
Number of children / dependents :
Education (Check highest level completed) :
Do you have management experience? :
Yes
No
Please describe your work and/or management experience: :
Professional Affiliations :
Professional Experience:
Self:
Spouse:
Current Employer :
Current Employer :
Address :
Address :
City/State/Zip :
City/State/Zip :
Position/Title :
Position/Title :
Current Salary net/year :
Current Salary net/year :
Beginning Date :
Beginning Date :
Job Description :
Job Description :
Previous Employment Experience - Past 5 Years
(List in order starting with most recent. Use additional pages, if necessary)
Employer :
Address :
From/To :
Position :
Income (net/year): $
How long have you been looking for a business opportunity? :
What types of businesses have you investigated? :
Three Personal References:
Name :
City :
Contact Information :
Relation Ship:
Home :
Cell:
Work:
Name :
City :
Contact Information :
Relation Ship:
Home :
Cell:
Work:
Name :
City :
Contact Information :
Relation Ship:
Home :
Cell:
Work:
Financial Information
*Current Financial Status (or attach current financial statement)
Assets
Amount
Cash & Savings Accounts :
$
IRA and 401 K Accounts :
$
Marketable Securities :
$
Money Due You from Others :
$
Residence (Market Value) :
$
Real Estate Other :
$
Automobile Owned (Not Leased) :
$
Household & Personal Goods :
$
Business Ownership-Market Value of Your % Ownership :
$
Other Assets :
$
$
$
Total Assets :
$
Liabilities
Total Payable
Monthly Payment
Credit Card Balances :
$ $
Income Tax Due :
$ $
Loans Payable Individuals :
$ $
Residence 1st Mortgage :
$ $
Residence Equity Loan :
$ $
Real Estate Loans :
$ $
Auto Loan(s) # 1 :
$ $
# 2 :
$ $
Other Bank Loans :
$ $
Other Liabilities :
$ $
$ $
$ $
Total Liabilities :
$ $
PERSONAL NET WORTH :
$
Reported Income:
Annual Salary
Spouse (if applicable)
Last Year's Annual Salary $(per W2 Box 3) :
Last Year's Annual Salary $(per W2 Box 3) :
Total Annual Salary :
$
The Future
Are you interested in a single Sharkey's or multiple Stores?
Single
Multiple
How Many?
Fill in Number
In which cities or areas would you like to open your business?
Preference: 1.
Preference: 2.
Preference: 3.
Do you plan to personally manage the business? :
Yes
No
If no, who will be responsible for the daily operation of the business?
When
would you be ready to start your business if you are approved for a Sharkey's Territory?
Please provide a short statement of your business objectives.
Was any special promise made to you by anyone associated with Sharkey's in connection with this application? :
Yes
No
If yes please explain:
Annual Reported Income to IRS: (Income Reported _ per your 1040 Tax Return - Page 1, Line 22)
Reported 2006 $
Reported 2005 $
Reported 2004 $
Tax Exempt Income (if applicable) $
Check all that apply:
Other Source:
Financial Statement Comments:
Cash Available for
investment in a Packaging and Shipping Specialists Business: $
Please state exactly where your down payment is coming from: (check one)
(explain)
Do you have additional sources of income not listed above?
What do you estimate is the amount of monthly income necessary to pay your current living expenses?
Home: $
Auto: $
Living: $
Other: $
Total Monthly Expenses: $
Will the business be your only source of income?
Yes
No
Don't know
Do you think your credit score is above 650?
Yes
No
Don't know
Estimated credit score:
Have you ever filed for bankruptcy?
Yes
No
If yes, when (MM/DD/YYYY)?
If yes, which chapter? (check):
If discharged, when (MM/DD/YYYY)?
In the last 10 years, have you been convicted of, or pleaded guilty to or no-contest to a felony or misdemeanor (other than a traffic violation)?
Yes
No
If yes please explain:
Are there any civil judgments against or current civil suits pending against you and/or your spouse?
Yes
No
If yes please explain:
Additional Information Our typical territory agreements are a five year term. Therefore, you must be able to legally reside and work in the United States of America for this term.
Please indicate your citizenship and/or immigration status:
if this you are not a citizen of the United States of America, you must attach proof of your legal right to reside and work in the United States of America.
To assure our compliance with Executive Order 13224, please have each applicant initial the appropriate statement below that is correct concerning the party applying for this license.
If applicant(s) is an individual:
I certify that I am not on and am not a member, related to, or associated with any organization on the list contained in the Annex to Executive Order 13224 and all updates thereto.
OR If applicant is a corporation:
On behalf of applicant organization, I certify that, to the best of said applicant corporation's knowledge, said applicant corporation is not owned or controlled by any person who is on or is a member of, related to or associated with any organization on the list contained in the Annex of Executive Order 13224 and all updates thereto (http://www.state.goV/s/ct/rls/fs/2002/16181 .htm).
I/We represent and warrant that all of the statements made by me/us in this application are true and correct. I/We understand that submitting this form does not constitute an agreement by either party and neither party is under any obligation. By signing this application the individual(s) name(s) herein give (Name of Franchise) or an assigned lender the right to contact all references and obtain whatever information deemed necessary to process this application. (Name of Franchise) and/or it's assigned lender is authorized to investigate my background, including employment history, personal references and educational background, as well as public records, including credit history, civil/criminal history and motor vehicle data.
APPLICANT (Please Print)
Name: First :
Ml :
Last :
Signature
(forms filed electronically will be considered signed if name is printed on the signature line)
Today's Date (MM/DD/YYYY):
SPOUSE (Please Print)
Name: First :
Ml :
Last :
Signature
(forms filed electronically will be considered signed if name is printed on the signature line)
Today's Date (MM/DD/YYYY):
