Lee Myles Franchise Information Questionnaire Form

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PERSONAL INFORMATION Customer Name: E-Mail Address: Day Phone: Date of Birth: Spouse's First Name: # of Dependents: 1 2 3 4 5 6 7 0 Have You Ever Been Convicted of a Felony? No Yes Have You Ever Declared Bankruptcy? No Yes Location Preferred:

How did you hear about Lee Myles? Newspaper Ad Reputation TV Radio Ad Web Site Search Engine

FINANCIAL INFORMATION
Do you have liquid assets of at least $60,000.00? Yes No
Can you Qualify for Financing of at least $60,000.00? Yes No Mabey

Comments or Questions:

I understand that this is a preliminary questionnaire and that in order to qualify for a Lee Myles Franchise I will have to complete a Qualification Sheet. This information is for the confidential use of Lee Myles Associates Corp. and I would like to be considered as a possible Lee Myles franchisee. I hereby authorize Lee Myles Associates Corp. to verify, through usual customary commercial channels, the information provided by me. I understand that I may request a copy of any report obtained by Lee Myles Associates Corp in verifying my financial position. I under stand that the signing of this application does not commit me or Lee Myles Associates Corp. in any way.

Prospective Franchisee (type full name): Date:

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