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CONFIDENTIAL FRANCHISE QUESTIONNAIRE

Name:

Address:

City:

State:

Zip Code:

Home Phone:

Office Phone:

E-mail Address:

Length of time at above address:

Previous Address:

Age:

Date of Birth: ( MM / DD / YY )

Social Security No:

Marital Status: Single Married

If married, name of spouse:

Number of Children:

Ages of Children:

Previous work experience, starting with the most recent:

Company	Address	Position	No of Years

Education:

Last year of school completed:

College Degree: Yes No

Health:

Health Status:

Illness/Disability:

Attorney:

Attorney's Name:

Telephone No:

Business Options:

Gateway Store Location(s) of Interest:

When are you available to open business:

Will you work in the business: Part-Time Full-Time

If Part-Time, please explain why:

Will you have a partner: Yes No

If so, will your partner be active: Yes No

Background Check:

Have you ever been convicted of a Felony or misdemeanor (other than a traffic violation) or are you currently involved in a criminal proceeding: Yes No

If yes, please state details:

Have you ever taken bankruptcy: Yes No

If yes, state place and date:

Reason for Bankruptcy:

Income Status:

What is your current annual income (including sources other than your salary):

References: (to be contacted after interview)

Name	Position	Address	Telephone No

Financial Information:

As of ( MM / DD / YY )

	Assets		Liabilities
Cash on Hand		Notes Payable
Securities		To Banks
Cash Value of Insurance		Due Others
Other Investments		Mortgages
Personal Items		Home
Autos		Real Estate
Home		Other
Other Real Estate		Installments/Loans
Value of other Business		Other Obligations
Other Assets

Total Assets		Total Liabilities
Net Worth

Bank & Credit References:

Name	Address	Telephone No

Credit Cards Held: VISA MasterCard American Express

Please note the items that you would convert to cash, if necessary, to meet the initial requirements of Gateway Newstands:

Financing:

Capital Available: $50,000.00 $75,000.00 $100,000.00 or more

Will you require assistance to obtain financing: Yes No

Business Contribution:

What do you feel will be your most important contribution to your business:

I, hereby declare that all the information provided herein is to the best of my knowledge true, complete and correct and I understand that it may be used to determine my credit worthiness. In order to assess my ability to meet my financial obligations, I authorize Gateway Newstands and its agents or assigns by submitting this on-line application: i) to request and obtain personal information about me on an ongoing basis from credit bureaus from information they previously collected about me in order to assess my credit history; ii) to exchange my personal information on an ongoing basis with credit bureaus in order to protect me, ensure the completeness of the information and maintain the integrity of the credit granting system; iii) to co-operate with local, provincial and national authorities in the investigation of unlawful or improper activities in order to protect me and you from fraudulent transactions; and iv) disclose your personal information where necessary to protect my interests, and yours. .