Request for Consideration

NOTE: Filling out this request for consideration does not obligate you or A Right Place for Seniors.The purpose is to create a solid basis of mutual understanding.

Applicant Information
Name HomePhone:
Email Address: CellPhone:
Fax OtherPhone:
Street Address City/State/Zip:
Do you: RentOwn How long at this address?
Current Occupation: How long in this occupation?
Education: Date of Birth:
Have you ever been convicted of a felony offense? YesNo
Marital Status: MarriedSingleDivorcedSeparated
If married, will your spouse participate in the business? YesNo
Spouse/Partner Information
Name: Email Address:
Current Occupation: How long in this occupation?
Annual Income:
Business Experience/Employment History
FROM - TO (YEARS) COMPANY/CITY POSITION ANNUAL INCOME
Business/Management Goals & objectives
Is your objective to: SupplementTransitionReplace your current incomeInvestBe actively involved
Specify the cities or areas and state you are interested in:
Why are you interested in the advertising/marketing industry?
How long have you been looking at business opportunities?
What other types of businesses are you considering?
How did you hear about A Right Place for Seniors?
What specifically about the A Right Place for Seniors Franchise Program appeals to you?
On a scale of 1 - 10, with 10 being the highest, how committed are you to owning your own business?
What is your timeline for starting your own business? (In months)
Why do you believe you can successfully operate and manage an A Right Place for Seniors Franchise Program?
Financial Disclosure
This information serves only to show your ability to make the necessary investment to successfully capitalize your business.
Assets Liabilities
$ Notes Payable to Banks $
Cash in Savings Account $ Notes Payable to Finance Companies $
Real Estate (Home Value) $ Real Estate Mortgage Indebtedness $
Other Real Estate $ Credit Cards $
Cash Surrender in Life Insurance $ Other Liabilities $
Qualified Plan Assets:
401K Assets $
IRA Assets $
Other Assets $
Total Assets $ Total Liabilities $
NET WORTH(total assets minus total liabilities) $
What amount of money do you feel comfortable investing? $
What is your liquid capital?
Have you ever filed for bankruptcy? NoYes (If yes, please attach a letter of explanation.)
On a scale of 1 - 10, with 10 being the highest, how committed are you to moving forward with A Right Place for Seniors Franchising?
Disclosure Statement
I understand the information I am receiving from A Right Place for Seniors or from a A Right Place for Seniors employee, agent, franchise, licensee or any of their affiliates is considered highly confidential. This material, concept and business model has been developed with a great deal of effort and expense to A Right Place for Seniors and is being made available to me because of my request and will be kept in strict confidence. I will not divulge or use any data, customer or employee names, addresses, techniques, methods, advertising materials, forms or any other information of any kind used in connection with A Right Place for Seniors without their consent.
SIGNATURE PRINT NAME DATE