Submit Application - LED Source Franchise Opportunity

Please fill out the information to the best of your knowledge and put N/A for information that does not apply.

Name*

First Middle Last

Address (please spell out State/Province)*

Street Address City State / Province / Region ZIP / Postal Code Country

How long have you lived at this address?*

Email*

Cell phone*

Home phone

Best time to call*

Morning
Afternoon
Evening

How did you hear about us?*

Desired location of franchise*

Secondary location of franchise*

Personal Confidential Information

Please fill out the information to the best of your knowledge and put N/A for information that does not apply.

Date of birth*

Have you ever filed for bankruptcy?*

Yes
No

If yes, when?

Marital status*

Single
Married
Divorced

Do you rent or own your home?*

Rent
Own

Citizenship*

How many dependents?

Business Background

Information about you

Please fill out the information to the best of your knowledge and put N/A for information that does not apply.

Present employer*

Present employer address*

Title*

Duties and Responsibilities*

Length of employment*

Salary of present employer*

Will you be leaving this employment to open your business?*

Yes
No

Any other source of income?*

Previous employer

Please fill out the information to the best of your knowledge and put N/A for information that does not apply.

Previous employer company

Previous employer address

Years employed

Previous employment position

Have you owned your own business?*

Yes
No

If yes, what type of business?

How long did it operate?

Was own business

Full-time
Part-time

Annual income of business

Current business status

About you

Please fill out the information to the best of your knowledge and put N/A for information that does not apply.

How did you become interested in LED Source®?*

How soon would you want to open your franchise?*

What are your primary reasons for going into your own business?*

Are you interested in obtaining a master license?*

Yes
No

If so, what country?

Will you have a partner in the franchise?*

Yes
No

Will any family members be involved in the business?*

Yes
No

What languages do you speak?*

Any other information you want to provide:*

Financial Information

Assets

Please fill out the information to the best of your knowledge and put N/A for information that does not apply.

Cash on hand & in banks*

Stocks, bonds and securities*

Retirement funds*

Notes & loans owed to you*

Home market value*

Other real estate*

Business owned value*

Other Assets*

Capital to invest*

Liabilities

Please fill out the information to the best of your knowledge and put $0 for information that does not apply.

Bank loans*

Notes payable to individuals*

Credit card balance*

Vehicle loans*

Home mortgage/rent*

Other real estate mortgages*

Student loans*

Other liabilities*

This is not a contractual agreement. The signing of this document does not obligate you in any way to purchase a LED Source(tm).The undersigned certifies that the information supplied is true and correct.