Please Choose One:	How did you get to Breadsmith.com? ---------------------------------- Linked from Bison.com Linked from Bizsale.com Linked from Franchise.org Linked from Franchise1.com Linked from Franchise-update.com Linked from Franchisegator.com Linked from Franchising.com Linked from Another Site ---------------------------------- Entrepreneur Magazine Entrepreneur Magazine 500 listing Franchise Handbook Magazine IFA Franchize Opportunities Guide Income Opportunities Platinum 200 Listing Successful Franchising Magazine ---------------------------------- Breadsmith Ad Breadsmith Store Other
If a Breadsmith Store:	Which Store? -------Arizona------- Mesa -------Illinois-------- Wells St., Chicago Highland Park Lombard Palos Heights Skokie St. Charles -------Indiana------- Indianapolis South Bend ------Michigan------- Birmingham Bloomfield Hills Grosse Pointe Woods Livonia Okemos -----Minnesota------ Edina Minnetonka St. Paul ------Missouri------- Springfield St. Louis -------New Jersey----- Cranford ----North Dakota----- Fargo --------Ohio-------- Cincinnati Fairlawn Lakewood West Chester ----South Carolina---- Fort Mill ----South Dakota----- Sioux Falls --------Texas-------- McAllen ------Wisconsin------ Appleton Green Bay Greenfield Milwaukee Wauwatosa Whitefish Bay

Name
Address
City
State
Zip Code
Home Phone
Work Phone
Okay to call at work?
E-mail Address
Social Security #
Marital Status
Spouse's Name

Name/Location
Dates Attended
Major
Degree

Military Service

Branch
From Date
To Date
Honorable Discharge?
Rank

Company Name/Location
From Date
To Date
Annual Income
Duties

Company Name/Location
From Date
To Date
Annual Income
Duties

1st Choice

Proposed City
State/Province
Population
Near What Major Cities

2nd Choice (if applicable)

Proposed City
State/Province
Population
Near What Major Cities

If approved, how soon could you begin operation?

How much of your net worth is Liquid?

Will any other family members or friends be involved in the operation of your Breadsmith^®?

Will you have business Partners?
(a separate application must be submitted for each partner)

Partner #1 Name
Telephone

Partner #2 Name
Telephone

Partner #3 Name
Telephone

How did you first hear about Breadsmith^®?
What caught your interest?

Have you ever been involved with a franchise? (if yes, system name and involvement)

Do you have any prior retail experience? (if yes, please detail)

Other than Breadsmith^®, what other business opportunities are you evaluating?

Please use this space to tell us anything else you think is relevant in the evaluation.

The above information is true and correct, and I hereby authorize Breadsmith Franchising, Inc. to investigate my background and credit history.

Completed By:

Date

If you choose not to fill out your financial statement online, scroll to the bottom of the page to submit your application.

Name
Date Prepared
Assets
Cash (checking) accounts
Cash (savings) accounts
Notes (contracts) owed to you
Treasury bills
Saving certificates
Life insurance (cash value)
Money market funds
Precious metals
Other assets (specify)
Securities (stocks, bonds) After Tax*
Real estate (market value)
Autos (market value)
Subtotal:
Retirement Plans:
401k
IRA's
Other retirement funds
Pension Subtotal:
Total Assets:
*Value you would net after paying capital gains taxes, brokerage commissions, etc.

Liabilities
Credit card obligations
Home mortgage
Other mortgages
Auto loans
Personal loans
Personal guarantees
Education loans
Business loan obligations
Taxes
Other debts
Total Liabilities:
Net Worth
Total Net Worth:

 

Annual Income
Your Salary
Spouse's salary
Interest
Dividends
Itemize other income
Total:

The above information is true and correct, and I hereby authorize Breadsmith Franchising, Inc. to investigate my background and credit history.

Completed By:

Date

Please Choose One I have chosen to fill out the application only. Please send me a financial form along with my informational packet. I have chosen to fill out the application and the personal financial statement. Please send a UFOC along with my informational packet.