Franchise Application Form

Please assist us by completing all sections carefully and thoroughly. If required you may provide additional, relevant details on the last sheet. Fill in as much as you can where it applies to you - if there is something that you cannot confirm, or complete for any reason, leave blank and if necessary state why in the additional information.
Personal Details
Title: Mr Mrs Ms
Forenames:
Surname:
Date Of Birth (DD/MM/YYYY):
Spouse/Partner name:
Address 1
Address 2
Address 3
Address 4
Postcode:
Country:
Home telephone:
Work telephone:
Mobile phone:
Email:
   
In which geographical area would you most like to operate in?

1st choice

2nd choice

3rd choice
Would you be willing to relocate?
   
Education
Please give details of higher education or any professional qualifications that you may have:
Please give details of your secondary education (Please list NVQ's/GCSE's/A Levels)
   
How and where did you hear of the Chemex franchising opportunities?
Interests, hobbies and community involvement?
   
Career History - Please start with your most recent employment
Start Date:
Finish Date:
Name/Address of employer:
Position Held:
Brief description of duties and responsibilities:
Salary:
Reasons for leaving:
   
Start Date:
Finish Date:
Name/Address of employer:
Position Held:
Brief description of duties and responsibilities:
Salary:
Reasons for leaving:
   
Start Date:
Finish Date:
Name/Address of employer:
Position Held:
Brief description of duties and responsibilities:
Salary:
Reasons for leaving:
   
Personal Financial Information - Please use your local currency (e.g. £, $, € etc.)
Salary/Draw (for the last 12 months):
Property Income:
Bonus/Commission:
Business profits:
Dividends/Interest:
   
Assets:
Cash on hand:
Shares/unites trusts:
Residential property current market value:
2nd property(ies):
Net value of Business Interests:
Motor Vehicles:
Total Assets:
Liabilities:
 
Loans:
Residential mortgage:
2nd property(ies) mortgage:
Accounts/Bills due:
Other debts or obligations:
Total Liabilities:
Net Worth:
   
General
How much free capital do you have available to invest in a Chemex Franchise?
Will you concentrate solely on the Chemex business?
Have you ever declared for IVA/bancruptcy? If yes, please explain.
Have you ever had a business failure? If yes, please explain.
   
Have you ever been convicted of a criminal offence (which is not a spent conviction within the terms of the Rehabilation of Offenders Act (1974)?
   
Please fill in the following field if you have any additional information that you would like to provide us: