Personal Information:

Name
E-mail address
Address line 1
Address line 2
City, State, ZIP

Best Time to Call:

Residence Telephone () - From: To:
Business Telephone () - From: To:

Date of Birth: Social Security Number:

Home:

Own
Rent
How Long?:

Market Preferences:

To what extent would you be actively involved in the operation of the Dr. Vinyl business?

Are you interested in developing a multiple van operation?

Yes
No

Education:

Highest Level Attained:

Military Service:

Were you in the Armed Forces?
Yes
No
If yes, what branch?
Rank at discharge
Date of service From To

Special Activities

What are your special interests and hobbies?

List memberships in civic or professional organizations:

Personal Information:

Spouse's name:
Spouse's Occupation:

Have you ever been adjudicated a bankrupt?

Yes
No

Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?

Yes
No
If so, describe:

Business Experience: (Give the most recent position first, explain self-employment experience.)

Company
Job Title
Address
Duties
Employed From To
Immediate Supervisor
Annual Salary or Compensation

Business Experience: (Give the most recent position first, explain self-employment experience.)

Company
Job Title
Address
Duties
Employed From To
Immediate Supervisor
Annual Salary or Compensation

Your Self Assessment

This analysis is designed to assist in determining the compatibility of your goals and insights with that of franchising.  Please check the boxes next to the letter(s) of your response.

1. What best describes you at your present job?

A. Easygoing
B. Take charge type of person
C. Analytical
D. Taskmaster
E. Follows instructions well
F. Excitable
G. Welcomes responsibility
H. Will make decisions if I have to

2. How do you regard your present job?

A. Like it very much
B. Job security is uncertain
C. Do not like it
D. I'm not paid what I'm worth
E. Lack of opportunity
F. I've spent too long doing it
G. Would change for a better job with another company

3. What prompted you to investigate a business opportunity?

A. Lack of opportunity in present job
B. Not earning what I'm worth
C. Wanted a business with spouse or family member
D. Comparing it to a non-franchised business
E. Fearful of present company's future
F. The timing seemed right

4. What is your timetable for being in business?

A. Haven't yet decided to go in business
B. One year
C. Three months
D. As soon as possible
E. Haven't thought about it
F. Six months

5. What adjective best describes your attitude about going into business?

A. Confident
B. Cautious
C. Fearful
D. Uncertain
E. Adventuresome

6. Which would provide you with the most satisfaction about owning your own business?

A. Making decisions
B. Building a future
C. Status
D. Earning what I'm worth
E. Working on cars

7. What do you consider to be the three most important factors in the failure of businesses?  (Choose three responses.)

A. Ineffective advertising
B. Poor management
C. Limited capital
D. No one can know everything necessary to run a business
E. Lack of business guidance
F. Attitude
G. No business formula
H. Wrong business field
I. Poor product mix
J. Lack of experience

8. What do you consider to be the two most important factors in joining a franchise network?  (Choose two responses.)

A. FTC disclosure document
B. How much capital is needed
C. What other franchisees say
D. Amount of support offered by franchisor
E. Net profit of business
F. Number of franchises in operation
G. Length of time the franchisor has been in existence

9. What would you consider to be the most important thing a franchisor could offer your business?

A. Product purchases at affordable prices
B. Training
C. Initial help in establishing accounts
D. Total support system that provides ongoing assistance
E. Advertising program

10. What do you feel is your strongest success characteristic?

A. Ability to work with people
B. Management talent
C. Sales ability
D. Ability to learn quickly
E. Seeing a task through to completion
F. Can make decisions

The information supplied herein is true to the best of my knowledge; I understand that necessary credit and reference inquiries may be made and I hereby authorize the release of such information to Dr. Vinyl and Associates, Ltd.

Name Date