Application Form

Business Experience
Work history and/or business owned.
Please attach resume if available
Accepted file types: doc, docx, pdf.
Present
Company
Position
Date Employed
Address
Street Address City State ZIP Code
Type of Business
Responsibilities
May we contact this company?
- Yes
- No
Contact Name
Contact Phone
Previous
Company
Position
Date Employed
Address
Street Address City State ZIP Code
Type of Business
Responsibilities
May we contact this company?
- Yes
- No
Contact Name
Contact Phone
Have you ever been convicted of anything other than minor traffic violations?
- Yes
- No
Has any judgment ever been entered against you or your company or your employer where you were one of the litigants?
- Yes
- No
Please Explain

Our Opportunity
How did you become aware of this license opportunity?
- Magazine
- Newspaper
- Store Visit
- Referral
- Trade Show
- Other
Name of Magazine
Name of Newspaper
Store Location
Who referred you?
Where was the trade show?
Please Describe
Where is the ideal location/town you would like to operate a shop?
Please list locations in order of priority.

Personal Financial Statement
Assets
Cash, Checking, Savings Account
Stocks, Bonds, Securities (non-IRAs)
Accounts/Notes Receivable
Other real estate - market value
Real estate - home market value
Life insurance - cash value
IRA, 401K or other retirement
Other Assets (itemize)
Total Assets
Liabilities
Loans, Notes (non-real estate)
Accounts and bills due
Total Credit Card Liabilities
Other real estate mortgage
Real estate - home mortgage
Taxes due
Other liabilities (itemize)
Total Liabilities
Net Worth
(Assets minus liabilities)
Liquid capital available (non-borrowed) to invest in this license?
Annual Source of Income
Salary
Bonus/Commissions
Dividends/Interest
Other Source
Specify
Total Income
Do you plan on being an owner-operator?
- Yes
- No
Do you plan to have a partner?
- Yes
- No
(All partners will need to complete Franchisee Application)
Will the partner be active?
- Yes
- No
Do you plan to have investors?
- Yes
- No
If so, to what extent?

Statement of Certification
I certify that the information in this application is true and complete. It is understood that the purpose of this questionnaire is to gather general information and is no way binding upon either the company or the applicant. It is, however, understood that the applicant supplies the information contained herein, to the best of his or her knowledge and ability, and that the company relies on this fact is assessing the desirability and qualification of the applicant. I acknowledge and understand that this application for a license in no way entitles me to any rights or benefits, including without limitation, the grant of the license rights for a Chock Full o’Nuts shop. I further acknowledge that the acceptance or rejection of this application is within your sole discretion.
By checking the box below you are providing your digital signature for this Statement of Certification.*
- I have read and sign the Statement of Certification

Franchising – Chock full o’Nuts