Franchising – Chock full o’Nuts Application Form Step 1 of 6 16% Personal InformationName Date of Birth MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Home PhoneBusiness PhoneFaxSpouse's Name # of Dependents/Ages Are you a citizen of the USA? Yes No Are you US resident alien? Yes No What is your visa status? Education RecordHigh School Last grade completed 8 9 10 11 12 Year College/University Major Degree Received Year Other Degrees or Training Courses Business ExperienceWork history and/or business owned.Please attach resume if availableAccepted file types: doc, docx, pdf, Max. file size: 256 MB.PresentCompany Position Date Employed Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Business ResponsibilitiesMay we contact this company? Yes No Contact Name Contact PhonePreviousCompany Position Date Employed Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Business ResponsibilitiesMay we contact this company? Yes No Contact Name Contact PhoneHave 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 OpportunityHow 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 StatementAssetsCash, Checking, Savings AccountStocks, Bonds, Securities (non-IRAs)Accounts/Notes ReceivableOther real estate - market valueReal estate - home market valueLife insurance - cash valueIRA, 401K or other retirementOther Assets (itemize)Total AssetsLiabilitiesLoans, Notes (non-real estate)Accounts and bills dueTotal Credit Card LiabilitiesOther real estate mortgageReal estate - home mortgageTaxes dueOther liabilities (itemize)Total LiabilitiesNet Worth(Assets minus liabilities)Liquid capital available (non-borrowed) to invest in this license?Annual Source of IncomeSalaryBonus/CommissionsDividends/InterestOther SourceSpecify Total IncomeDo 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 CertificationI 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