Franchise Application Electronic Franchise Application Form Name(Required) Gender Male Female Home Address(Required) City(Required) State(Required) Zip Code(Required) Mobile Phone(Required) Home Phone Work Phone Best Phone to Contact(Required) Mobile Home Work Best Time to Call(Required) Email Address(Required) Employer (Not required, but recommended) Job Title (Not required, but recommended) Marital Status(Required) Single Married Other Number of Dependents(Required)Spouse's Name (Not required, but recommended) Spouse's Employer (Not required, but recommended) Spouse's Job Title (Not required, but recommended) Spouse's Cell (Not required, but recommended)Will Someone other than your spouse be involved in the ownership and operation of the business with you?(Required) Yes No If yes, please list the names: When are you looking to open your business?(Required) When are you available to attend one of our weekly training sessions?(Required) Where would you like to locate your business?(Required) If your first choice is not available, what would your next two choices be?(Required) Have you ever had any criminal or civil actions filed against you?(Required) Yes No Please list names and phone numbers of three sources of reference. (Not required, but recommended)Do you have sufficient funds to support yourself and your dependents for at least 6 months as your business is in the development phase as well as initial operating capital?(Required) Yes No Cash on hand and unrestricted in banks?(Required)Other stocks and bonds?(Required)Other liquid assets (401k etc.)(Required)Home (Real Estate)(Required)Accounts and loans receivable(Required)How much are your monthly living expenses?(Required)How much net income (minimum) do you need the business to generate for you?(Required)What is your current credit score?(Required)Describe your professional experience. (Not required, but recommended)What attracted you to the home healthcare business? (Not required, but recommended)How much time per week will you dedicate to this business?(Required) Will you be operating the business on a full time basis? IF "NO", who will?(Required) What are your strongest skills in business? (Not required, but recommended)Consent (This is a non-binding application and it can be withdrawn at any time. No fees required. This is not a contract.1 Please, fill out this application and fax it to 954-858-4832 or email to alizaderay@interimhealthcare.com)(Required) I agree to the below.It is understood and agreed that any agreement entered into between Company and the prospect is predicated upon the truthfulness of statements in this report. I hereby authorize and request any and all of my former employers and others, unless otherwise indicated, to furnish a complete history of my services with them, together with any information they may have concerning my personal character, habits, ability, disposition, etc. and particularly a statement of the cause of termination of my employment. I hereby release them from any and all liability for damages of whatsoever nature as a result of furnishing the requested information. This is to inform you that, as part of our procedure for processing your application, an investigative report may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living, whichever may be applicable. You have the right to make written request, within a reasonable period of time, for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. The above information is true to the best of my knowledge and belief, and is submitted in support of my seeking approval for an Interim Healthcare Inc. franchise. EmailThis field is for validation purposes and should be left unchanged. Δ