Permaglaze - Personal Profile Application

PERSONAL PROFILE APPLICATION
This confidential report is designed to ascertain potential compatibility and financial stability.

General Information

Full Name:
Social Security Number:
Date of Birth (MM/DD/YY):
Height:
Weight:
Sex:
Address:
City:
State:
Zip:
Email Address:
U.S. Citizen:
Do you rent or own?
How long there?
Are you married?
Spouse's Name:
Occupation:
How were you referred to Permaglaze?
Home Phone:
Business Phone:
May We Contact You at Either?
In what capacity are you presently employed or in business?
Describe your affiliation with any other businesses:

Employment and Business Experience

From:
Until:
Name of business or firm:
Position:
Reason for leaving:

From:
Until:
Name of business or firm:
Position:
Reason for leaving:

From:
Until:
Name of business or firm:
Position:
Reason for leaving:

From:
Until:
Name of business or firm:
Position:
Reason for leaving:

Have you ever declared bankruptcy?
Do you have any unsatisfied judgements or civil suits pending?

Business References

1st Individual:
Title:
Company:
Location:
Phone:

2nd Individual:
Title:
Company:
Location:
Phone:

3rd Individual:
Title:
Company:
Location:
Phone:

Personal References

1st Individual:
City/State:
Years Known::
Phone:

2nd Individual:
City/State:
Years Known::
Phone:

3rd Individual:
City/State:
Years Known::
Phone:

Confidential Financial Statement

ASSETS
Cash in Savings:	$
CD's or IRA's:	$
Real Estate:	$
Vehicles:	$
Other Assets:	$

LIABILITIES
Credit Card Balances:	$
Mortgages:	$
Vehicles:	$
Other Liabilities:	$

Management Plan

1st Geographic Location Preference:
2nd Geographic Location Preference:
Based on mutual agreement, what date would you like to start?
How do you plan to finance your investment?
Are there any other investors/associates who would join you in this venture?
Will you attend training by yourself or with another person?
What net income do you foresee from your association with this franchise opportunity?
First Year:	$
Second Year:	$
Third Year:	$

Self Appraisal

Are you generally optimistic about life?
Do you focus on the rewards of success more than the penalties of failure?
What are some of your greatest strengths?
What are some of your greatest weaknesses?
What is your most important lifetime goal?
Do you usually complete the projects you begin?
Do you find security in your present lifestyle?
What do you feel are some of the factors that would determine the difference between success and failure in your business?
Describe any medical restrictions or allergic conditions:

Signature

By placing your initials in the box to the right, you signify that, to the best of your knowledge, the information you have submitted is correct and you authorize PERMAGLAZE to make any necessary inquiries (concerning this information) to financial institutions and/or credit agencies.

Comments

Please use this space to tell us about any other qualities you may have that would prove to be mutually beneficial should you join our organization.