Confidential

Partner Program Evaluation Application Form

This form will aid you in preparing and presenting personal information for confidential use. Please complete the form in as much detail as possible.

PERSONAL DATA AND BUSINESS HISTORY

Must be filled out completely by all parties (or shareholders of corporations)

General Information:
Name:
Address:
How long at address:
City:
State:
Zip/Postal Code:
Social Security Number:
Date of Birth:
Name of Spouse (if married):
Home Phone:
Business Phone:


Business Experience:
From To Firm Position Income
Do you now, or did you ever own a franchise? Yes No
If Yes, please explain:
Are there any lawsuits pending against you? Yes No
If Yes, please explain:
Have you ever failed in business, compromised with creditors or filled bankruptcy? Yes No
If Yes, please explain:
Have you ever had any type of license revoked or suspended? Yes No
If Yes, please explain:
Have you ever been convicted of a crime except minor traffic violations? Yes No
If Yes, please explain:
How is your health?
Are you a U.S. Citizen?
Do you own any patents or Copyrights?
Please list your hobbies:
Please list Education:
How did you learn about Flagroup.com?

FINANCIAL DATA

Assets:

Liabilities:
Cash:  Notes Payable: 
Securities - readily negotiable:  Real Estate debt: 
Cash surrender value:  Installment Payable: 
Real Estate - fair market value:  Others (specify):
Equity in business - liquid:
Equity in business - non-liquid:
Others (please describe):
TOTAL: TOTAL:

MANAGEMENT PLANS
When would you be able to begin this venture?
Territory in which you are interested:
First Choice
Second Choice
Are there any investor-associates who would join you in this venture? YesNo
If Yes, please give their names and have each fill out one of these forms:

REAL ESTATE EXPERIENCE
Do you operate a real estate office now? YesNo
Type of License:
Was License ever revoked or suspended? YesNo
Year in Real Estate:
Education (years and Degrees):
Professional Designations:
How is your business activity distributed?
% Residential
% Commercial
% Other
Past or present position on Local/state board of Realtors:
Have you ever operated (or worked under) a 100% system? Yes No
If Yes provide details:
Where:
When:

REFERENCES

Business References:
Full Name *:
Title *:
Company *:
Address *:
Telephone *:
E-Mail Address 
Full Name :
Title :
Company :
Address :
Telephone :
E-Mail Address 
Full Name :
Title :
Company :
Address :
Telephone :
E-Mail Address 

Character References:
Full Name :
Title :
Company :
Address :
Telephone :
E-Mail Address 
Full Name :
Title :
Company :
Address :
Telephone :
E-Mail Address 
Your Personal Bank Contact
Address Phone
Your Business Bank Contact
Address Phone
Memberships (Civic, Business, professional)

COMMENTS
Please provide any additional comments that may be helpful:
By submitting this form I declare that to the best of my knowledge and ability the information that I submit is correct and that I authorize the release of my credit report by a local credit agency.