PERSONAL DATA

Name:

Date:

Address:

City:

State:

Zip Code:

Home Phone:

E-mail:

Business Phone:

Social Security No.:

Driver's License No.:

Date of Birth: 

Spouse's Name:

Spouse's Date of Birth: 

Spouse's Occupation:

Dependents and Ages:

Any other name by which you are known (state details)

If at current residence less than 2 years, please provide previous residence.

Previous residence

Dates at this address

Are you a citizen of the USA?

Yes

No

If not, what country? 

Have you ever been convicted of, or pled guilty or no contest to, a felony or misdemeanor (other than a minor traffic violation) ?

Yes

No

If yes, please state details:

EDUCATION

Name and Location

Year Graduated

Major or Degree

High School

College

Graduate

PERSONAL REFERENCES

Name

Telephone

Association

BUSINESS EXPERIENCES (Work history and/or business started)

Please give present or last position first, and provide the last 10 years of work/business history.

1. Company:

City, State:

Type of Business:

Employed from: 

to:

Position:

Major Accomplishments:

Can we contact this company?

Yes

No

Contact person:

Telephone:

2. Company:

City, State:

Type of Business:

Employed from:

to:

Position:

Major Accomplishments:

Can we contact this company?

Yes

No

Contact person:

Telephone:

PERSONAL BALANCE SHEET

ASSETS

LIABILITIES

Cash on Hand and in Banks

Loans, Notes, Mortgages Payable $

Stocks and Bonds

Accounts and Bills Due

Account/Notes Receivable

Taxes Due

Real Estate Investments

Liens Payable

Net Value of Business

Other Liabilities (itemize)

Life Insurance - Face Value

Life Insurance - Cash Value

Other Assets (itemize)

TOTAL ASSETS

TOTAL LIABILITIES

TOTAL NET WORTH (Assets - Liabilities)

Capital Available to Invest in this Franchise

I authorize you to make investigations of my credit, character and ability, and to contact anybody, whether or not listed above, including former employers, in order to obtain personal information about me.  I release all such persons from any liability or damages that may be incurred as a result of the furnishing of such information.  I also certify that all the information in this application is true and complete.

AUTHORIZATION TO OBTAIN CREDIT

  I authorize G. C. & K.B. Investments, Inc., d/b/a SpeeDee Oil Change & Tune-Up to verify my references and obtain an Equifax credit report from CSC Credit Services Omaha, through their re-seller, creditchecks.com, a subsidiary of Landmark Management Group, Inc.

NAME:

DATE:

SOCIAL SECURITY NO.:

ADDRESS:

CITY:

STATE:

ZIP: