Bear Creek Coffee - Business Opportunities

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Please complete this questionnaire in its entirety. If you have a partner other than a spouse, please have each party complete this questionnaire. The purpose of this questionnaire is to provide general information to help evaluate your qualifications for being awarded a Bear Creek Coffee Business. The information you provide will be held in the strictest confidence.

This business opportunity is currently not available in California

COMPLETING THIS APPLICATION
DOES NOT OBLIGATE EITHER PARTY IN ANY MANNER

Required information is indicated with an asterisk (*)

*Name:
*DOB:
*Spouse/Partner:
*DOB:
*Address:
*City:	State: Zip:
*E-Mail Address:
*Business Phone:	*Best Time To Call:
*Home Phone:	*Best Time To Call:
Cell Phone:	Best Time To Call:
*Marital Status:	# of Dependents: Ages:

Employment History
*Current Business or Employment:	*Position:
*Annual Salary:
*Responsibilities:

*Education (Check the Levels Completed)
High School College Other (Please Elaborate):

Spouse/Partner's Employment History
*Current Business or Employment:	*Position:
*Annual Salary:
*Responsibilities:

*Spouse/Partner's Education (Check the Levels Completed)
High School College Other (Please Elaborate):

Business and Management Goals
Do you plan to devote your full time to this business venture?
Yes No Comments:
Will your spouse/partner be active in the business opportunity?
Yes No Comments:
Will this business opportunity be your primary source of income?
Yes No Comments:
Have you ever owned a business?
Yes No Comments:
If yes, what type?
*List other affiliations, organizations, clubs, etc.


Financial Statement (please include as much information as you feel comfortable)

Assets
Cash On Hand Or In Bank:	$
Home:	$
Stocks And Bonds:	$
Personal Property:	$
Autos:	$
Other Real Estate:	$
Retirement, 401(K), IRA, etc.:	$
Other:	$
Total Assets (A):	$

Liabilities
Installment Notes & Contracts:	$
Real Estate Loans:	$
Bills Payable:	$
Other:	$
Total Liabilities (B):	$



Net Worth (A - B):	$

Please describe in detail from what sources and in what dollar amounts your initial and ongoing capital requirements will come.

What annual income do you feel you must realize:
1st Year: $ 2nd Year: $3rd Year: $
Your present annual salary range (in thousands):
$20-40 $40-60 $60-80 $80-100 Over $100
Have you ever filed bankruptcy?	Yes No
Have you ever been convicted of a felony?	Yes No
Personal and professional goals:


I certify that the information I have provided is complete and correct. It is understood that the purposes of this questionnaire is for general information and is in no way binding upon the franchisor or the undersigned. THIS IS NOT A CONTRACT. I authorize release of this information to Bear Creek Coffee Company Vendors only after purchase of a Bear Creek Coffee Company business.
* Please enter your initials to agree to the above statement