PERSONAL DATA

Name Social Security    
Home Address City State Zip
Home Phone Cell Phone Email
Business Phone Fax Pager
Date of Birth Place of Birth Marital Status
Spouse's Name Spouse's Occupation How Long?
Child's Name Age Child's Name Age
Child's Name Age Child's Name Age
Previous Address How Long?
City State Zip
Are you a U.S. Citizen Yes No If not, what Country?

PERSONAL REFERENCES (PROVIDE AT LEAST THREE)

Name Phone
Home Address City State Zip
Name Phone
Home Address City State Zip
Name Phone
Home Address City State Zip

EDUCATION

Name of High School Years Completed
Name of College Degree
Name of College Degree

Describe any training in sales, management, or retail:

Date:

EMPLOYMENT HISTORY FOR LAST 10 YEARS (beginning with the most recent)

Company Name From To
May we contact this employer Yes No Contact Name Phone
Address City State Zip
Type of Business # of Employees Supervised
Describe Responsibilities:
Company Name From To
May we contact this employer Yes No Contact Name Phone
Address City State Zip
Type of Business # of Employees Supervised
Describe Responsibilities:
Company Name From To
May we contact this employer Yes No Contact Name Phone
Address City State Zip
Type of Business # of Employees Supervised
Describe Responsibilities:

BUSINESS REFERENCES (provide at least three)

Name Phone
Home Address City State Zip
Name Phone
Home Address City State Zip
Name Phone
Home Address City State Zip

BUSINESS DATA

How did you learn about the On Site Lube proprietor program?

Do you now operate or have you had experience in automotive industry?
If yes, explain:
Yes No

Do you intend to devote yourself full-time to the day-to-day operation of a On Site Lube business? explain :

Yes No

Have you (and, if applicable, partners, officers, directors or shareholders) been subject to or convicted of any administrative, criminal or civil action alleging a violation of any franchise law, fraud, embezzlement fraudulent conversion, restraint of trade, unfair of deceptive practices, misappropriation of property or comparable allegations ?
If yes, explain:

Yes No
Have you (and, if applicable, partners, officers, directors or shareholders) ever been adjudged bankrupt or reorganized due to insolvency, or been a principle officer of any company or a partner in any partnership that was adjudged bankrupt or reorganized due to insolvency?
If yes, explain:
Yes No
Are you willing to relocate? Yes No
Geographic location preference? Yes No
First Choice
Second Choice
Third Choice
What date do you plan to open your first On Site Lube Service ?  

PERSONAL FINANCIAL STATEMENT

ASSETS

 

LIABILITIES

 
Cash on hand and in banks $ Notes payable to banks - secured and unsecured $
U.S. government securities $ Notes, loans, advances, accounts payable $
Trade accounts and loans receivable $ Credit card debt $
Notes receivable - secured and unsecured $ Loan against life insurance $
Life insurance - cash surrender value $ Property taxes and assessments payable $
Stocks and bonds - Marketable and not $ Mortgages payable on real estate $
Real Estate $ Liens on real estate $
Automobiles - market value $ Federal and state taxes on current income $
Other assets, property, or investments (itemize below)   Other debts (itemize below)  
$ $
$ $
$ $
$ $
       
TOTAL ASSETS $ TOTAL LIABILITIES $
       

ANNUAL SOURCES OF INCOME

NET WORTH

 
Salary $ Total assets $
Bonus and commissions $ Less total liabilities $
Dividends and interest $ NET WORTH $
Real estate income $    
Business profession income $    
Other income (itemize below)      
  $    
  $    
  $    

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I hereby attest to the accuracy of the financial statements contained in this confidential On Site Lube Service application. I authorize On Site Lube Service or its agents to verify the data submitted, to obtain a consumer credit report and to make such additional credit, background,
or character confirmation which it deems necessary or advisable.

In connection with these financial and background investigations, I authorize On Site Lube Service. or its agents to contact present or past employers, schools, financial institutions, law enforcement agencies and any other person, firm corporation or source. I authorize any such source to provide On Site Lube Service or its agents all information concerning me, and I hereby release any such source and its agents and employees from all liability for providing this information. I understand such reports may contain information concerning my education, employment, work habits, character or skill, criminal and credit history.

I authorize that any photocopy or facsimile of this document may be accepted with the same authority as the original.

On Site Lube agrees to maintain in a confidential manner and restrict the use of any information contained or obtained in connection with this application for a On Site Lube franchise. I authorize On Site Lube to release to prospective financing sources any information concerning me that may be requested by them.

By checking this box, I certify that the above statements are accurate. THIS COPY WILL NEED TO BE REVIEWED BY AN ATTORNEY.

Value - Our services reduce costly mechanical repairs and eliminate unnecessary wages associated with down time for drivers and service personal during regular business hours. Our services allow your company to focus on its core business. See how we can help your business!