Franchise Application - Gold Star Franchise

First Name*

Last Name*

Home Phone*

Business Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Name of Applicant*

Date of Birth*

Are you a US Citizen?*

Drivers License # or State ID#*

Drivers License State*

Do you have the funds necessary to open a Gold Star Franchise?*

Are you a defendant in any lawsuits or legal action?*

Are you a Veteran?*

Have you ever filed bankruptcy or are you in the process of filing bankruptcy?*

Have you ever been convicted of a felony or misdemeanor (other than traffic violations)?*

Assets

Cash on Hand & in Banks

Savings Accounts

IRA or Other Retirement Account (Describe in Section 5)

Accounts & Notes Receivable (Describe in Section 5)

Life Insurance-Cash Surrender Value Only (Describe in Section 8)

Stocks and Bonds

Real Estate

Automobiles (Describe in Section 5, and include Year/Make/Model)

Other Personal Property (Describe in Section 5)

Other Assets (Describe in Section 5)

Total

Liabilities

Accounts Payable

Notes Payable to Banks and Others

Installment Account (Auto)

Installment Account (Auto) Mo. Payments

Installment Account (Other)

Installment Account (Other) Mo. Payments

Loan(s) Against Life Insurance

Mortgages on Real Estate

Unpaid Taxes (Describe in Section 6)

Other Liabilities (Describe in Section 7)

Total Liabilities

Net Worth

Total

Section 1: Source of Income

Salary

Net Investment Income

Other Income (Describe below)

*Alimony or child support payments should not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income

Real Estate Income

Description of Other Income

Contingent Liabilities

As Endorser or Co-Maker

Legal Claims & Judgements

Provision for Federal Income Tax

Other Special Debt

Section 5: Other Personal Property and Other Assets

(Describe, and, if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and, if delinquent, describe delinquency.)

Section 6: Unpaid Taxes

(Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7: Other Liabilities

(Describe in detail)

Section 8: Life Insurance Held

(Give face amount and cash surrender value of policies – name of insurance company and Beneficiaries.)

Consent*

I authorize the SBA/Lender/Surety Company to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness.

By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with this form is true and complete to the best of my knowledge. I understand that SBA or its participating Lenders or Certified Development Companies or Surety Companies will rely on this information when making decisions regarding an application for a loan or a surety bond.*

Print Name*

Date*