EMPLOYMENT

Please list beginning with most recent. Please provide time lines and brief summary of tasks and responsibilities.

EDUCATION
Please list beginning with most recent. Please provide time lines and certification attained.



PERSONAL AND FINANCIAL GOALS

What are your reasons for going into your own business?
Want to have greater control over my work, my career and my future
Want to build financial security for myself and my family
Have had enough working for someone else
Want to increase my income
Other (please explain briefly)


I want to operate my business (please select)
As an Owner/Operator
With my Spouse
With my Children
With a Partner

BUSINESS INFORMATION

Geographical Area(s) of Interest

I am interested in
A Single Unit License (1 Territory)
Multi Unit Territory (2 to 4 Territories)
Area Development (5 to 10 Territories)

What source created interest in Take-A-Break?
Newspaper
Radio
Television
Internet
Friend/Business Referral

At what stage do you consider your interest in a Take-A-Break License?
Mildly Interested
Very Interested
Ready to Start

In what timeframe do you want to be in business?
30 days
60 days
90 days

PLEASE READ AND CONFIRM:
The information provided herewith is is accurate and complete to the best of my knowledge. I authorize Take-A-Break Publications or its agents to obtain verification of any of the above information and authorize the release of such information to Take-A-Break Publications or its agents.

Date:



Applicant authorization: