Franchise Application

Personal Information

Name (Legal)*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Are You Married?*

Yes
No

Are you a US Citizen?*

Yes
No

Are your a Veteran?*

Yes
No

Have you ever been convicted of a felony?*

Yes
No

Experience

Are you currently employed?*

Yes
No

Have you ever owned your own business?*

Yes
No

Assets

Liquid Capital Available*

Savings Account

Investment Accounts

IRA or Other Retirement Account

Life Insurance - Cash Surrender Value Only

Accounts and Notes Receivable

Real Estate

Other Assets

Total Assets*

Liabilities

Mortgage Amount*

Auto Loans*

Other Debts*

Total Liabilities*

Annual Sources of Income

Salary*

Net Investment Income*

Real Estate Income*

Other Income (describe below)*

DESCRIPTION OF OTHER INCOME IN THIS SECTION:*

Is spousal income and expenses included in total income and expenses?*

Yes
No

Total Annual Income:*

Net Worth (Assets - Liabilities)*

Investment & Financing

How much capital are you willing to invest?*

Will you need financing?*

Yes
No

Comments

Consent

I authorize Well Franchise LLC to make inquiries as necessary to verify the accuracy of the statements made and to determine my credit worthiness. I certify that the above information and the statements contained in the attachments are true and accurate as of the stated date(s). I understand that FALSE statements may result in forfeiture of any position obtained in the process of acquiring a Well Health & Chiropractic Franchise and may eliminate any chances of obtaining a Well Health & Chiropractic Franchise or its affiliates in the future.

For Franchise Information, call (615) 517-4501