Application - Request for Consideration

Personal Information

1. *First Name
2. *Last Name
3. *Address
4. -Address 2
5. *City
6. *State Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. *Zip Code
8. *Home Phone
9. OK to contact here?
10. -Cell Phone
11. OK to contact here?
12. *E-mail
13. OK to contact here?
14. -Married
15. -Spouse's Name
16. -Spouse's Occupation
17. -Names & Ages of Children

Professional Information

1. Employer
2. # of Years
3. City/State
4. Phone
5. Do you have management experience?
6. How Long?
7. Do you have sales experience?
8. How Long?
9. Do you have technical experience?
10. How Long?
11. Have you ever owned or operated a business in the past? Please explain.

Business References

1. #1 Name    Years Known    Telephone
2. #2 Name    Years Known    Telephone
3. #3 Name    Years Known    Telephone

Financial Information

1. Cash Available
   What do you have available for this Business?
2. Real Estate
   What is the Value of Current Real Estate?
3. Annual Income
   What is Your Current Annual Income?
4. Annual Income
   What was Your Average Annual Income for the Past 3 Years?
5. Additional Funds
   Do You Have Access to Additional Funds?
6. Possible Funding Source
   List Source of Loan for Business?
7. Net Worth
   What is Your Total Net Worth?
8. Partner
   Will You Have an Equity Partner in Your Business – Who?

Territory of Interest

1. Primary Territory
   List Primarily City and State Interested In
2. How Many Territories are you Interested in Starting With?
   List Secondary Territory - City and State

Signature Authorization

1. I certify that the above information supplied by me is true and correct and that I am a bone fide franchise candidate who agrees not to make unauthorized disclosures of any of NerdsToGo’s confidential information or to use it for any purpose other than evaluating its franchise offer. I agree to provide additional information if required by NerdsToGo and authorize release of any information, from any source, deemed necessary by NerdsToGo to verify any and all of the above information. I further authorize NerdsToGo the release to NerdsToGo of any information regarding my character, credit standing or past employment. This authorization is good for twelve months.

   *Signature (Typing name in this field authenticates application and signature)