Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS
QUALIFICATION QUESTIONNAIRE
T o be o n yo ur w a y t o o w n in g your v e r y o w n C a ree rs U SA f ra nc his e ,
s im p l y co mp l e t e o u r Co nf i de nt ia l Q ua l i fi ca t ion Q ue s t io nn a i r e . Yo u m a y
c hoo se to p r i nt t h is fo r m a n d fax o r ma i l to o ur Fr anc h ise De par t me nt,
o r yo u m ay co m p let e o ur o n li ne a ppl i cat io n.
O n ce w e rec e iv e yo u r i n fo r ma t io n, w e w i l l be g i n o u r r e v i e w im med i a t e l y.
P l e a s e res t a s s ur e d t ha t yo ur i nfo r ma t io n w i l l be ke pt s t r ic t ly
c o n f i de nt ia l a t a ll t i mes .
P l ease fax o r ma i l t he co m p let e d f or m to o ur F ra nc his in g De pa rtm e nt.
Fax:
5 6 1- 99 5- 7 00 1
M ail:
C a ree rs U S A , I n c .
A t t n : T r udy Fe l d man, E x e c ut iv e V ic e P re s i de nt , F ra n chi s e De ve lop m e n t
6 5 0 1 Co n gres s Av e . , Su i t e 20 0
B o ca R a t o n, F L 3 3 48 7
Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS
CONTACT INFORMAT ION
first name
m. i.
last name
city
state
.
street address
country
day phone
evening phone
fax
e-mail
social security number
driver's license number
when is the most convenient time to call?
PE RSON AL /FAMILY
Have you ever been convicted of a crime other than a traffic violation?
.
YES / NO
if "yes," please explain
Are you a U.S. citizen?
.
YES / NO
if "no," state country of citizenship
marital status?
.
Single / Married / Separated / Divorced / Widowed
Spouse's Name
S. S. #
Child’s name:
Age:
.
Child’s name:
Age:
.
Child’s name:
Age:
.
Child’s name:
Age:
.
Child’s name:
Age:
E D U C ATION & A CT IVI TI ES
School
Major
Yrs. Compl.
YR Graduated
Degree
.
.
Have you ever received special training in management?
.
YES / NO
if "yes," please describe:
Have you ever received special training in sales?
.
YES / NO
if "yes," please describe:
Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS
B USIN ESS/P ROFE SSION AL /CIVI C ORGANI ZATIO NS
Business
.
.
Professional
.
.
Civic
.
M I L I TAR Y
Have you ever served in the U.S. Armed Forces?
.
YES / NO
If yes, which Branch?
Dates of duty
From
To
Rank at discharge?
B USIN ESS O R SEL F-E MPLOYMEN T HIS TO RY
1.
Date Started
Date Finished
Company Name
Department
Street Address
City
State
Zip
.
.
.
.
Telephone
Supervisor
Job Title
Annual Salary
.
.
.
May we contact?
YES / NO
Job Title
.
Description of Responsibilities
.
.
Reason for Leaving
.
2.
Date Started
Date Finished
Company Name
Department
Street Address
City
State
Zip
Telephone
Supervisor
.
.
.
.
.
Job Title
Annual Salary
.
May we contact?
YES / NO
Job Title
.
Description of Responsibilities
.
.
Reason for Leaving
.
3.
Date Started
Date Finished
Company Name
Department
Street Address
City
State
Zip
.
.
.
.
Telephone
Supervisor
Job Title
Annual Salary
.
.
May we contact?
YES / NO
Job Title
.
Description of Responsibilities
.
.
Reason for Leaving
Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS
F IN AN CI AL D A T A
Assets
Available Cash in Bank:
Account 1 Value
Account 2 Value
Account 3 Value
Stocks and Bonds:
Stock Value
Bond Value
IRAs and Insurance:
401(k) Vested Value
Real Estate:
Property Value
Life Insurance (Cash Surrender Value)
Property Value
Automobile(s):
Auto Net Value
Personal Property:
Description & Net Value
Auto Net Value
Description & Net Value
Other Assets:
Description & Net Value
Description & Net Value
Liabilities
Notes Payable to Bank:
Loan 1
Loan 2
Mortgage 1
Mortgage 2
Revolving Accounts:
Payment 1
Payment 2
Payment 3
Outstanding Taxes:
Amount Due
Child Support/Alimony:
Amount Due
Other Liabilities:
Amount Due
Amount Due
Amount Due
Amount Due
Bank
Notes Payable to Bank:
Loan 1
Loan 2
Mortgage 1
Mortgage 2
Revolving Accounts:
Payment 1
Payment 2
Payment 3
Outstanding Taxes:
Amount Due
Child Support/Alimony:
Amount Due
Other Liabilities:
Amount Due
Amount Due
Amount Due
Amount Due
Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS
Other Financial Information
Do you have an established source/backer of funding?
YES / NO
If yes, please explain.
Have you ever filed for bankruptcy?
YES / NO
If yes, please explain.
Have you ever owned/partnered a business?
YES / NO
If yes, please explain.
1.
REFERE NCES
Name
Relationship
Address
City, State Zip
Phone
Years Known
May we contact?
>1, 1-3, 4-6, 7-10, or 10+
YES / NO
2.
Name
Relationship
Address
City, State Zip
Phone
Years Known
May we contact?
3.
>1, 1-3, 4-6, 7-10, or 10+
YES / NO
Name
Relationship
Address
City, State Zip
Phone
Years Known
May we contact?
>1, 1-3, 4-6, 7-10, or 10+
YES / NO
GENERAL
List your location preferences (in order):
1.
2.
3.
4.
Why would you like to be in business for yourself?
If your application is approved, when could you begin training in our Headquarters in
Boca Raton, Florida?
How did you hear about Careers USA?
Please list any other franchise
opportunities you currently are
investigating:
1.
2.
3.
4.
5.
How will you participate in the operation of this franchise?
Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS
ADDITIONAL INFORM ATION
If you would like to provide us with any additional information, feel free to do so here.
I am certifying the information set forth in this application and my personal statements
to be true as of this date. I further certify that there is no judgment against me, no
lien unsatisfied upon my property except as shown and no suit pending against me in
any court. This application does not obligate either party as a result of its
submission.
PRINT NAME
SIGNATURE
DATE
Careers Franchising, Inc., 6501 Congress Avenue, Suite 200, Boca Raton, FL 33487
t: (561) 995-7000 f: (561) 995-7001 toll free: 1-888-CAREERS