ZEN MASSAGE FRANCHISE APPLICATION FOR CONSIDERATION
PERSONAL DATA
Date ___________________________ Name (First, Middle, Last) _______________________________________________________________ Social Security _____________________________________________
Home Address ______________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________ Home Phone ________________________________ Business Phone _____________________________ Date of Birth _________________________________ Spouse’s Name ______________________________ Cell Phone______________________________ Email _____________________________________________________ Fax ___________________________________ Pager _____________________________________________________ Place of Birth _______________________ Marital Status ______________________________________________ How Long? ____________________________
Spouse’s Occupation __________________________________
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 US 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 ______________________________________________________________________________________________________________________________________ Name ________________________________________________________________ Phone ____________________________________________________
Home Address ______________________________________________________________________________________________________________________________________ City, State, Zip ______________________________________________________________________________________________________________________________________
EDUCATION
Name of High School ___________________________________________________________________ Name of College _______________________________________________________________________ Name of College _______________________________________________________________________ Years Completed ________________________ Degree ________________________________ Degree ________________________________
Page 1 of 6
EMPLOYMENT HISTORY FOR LAST 10 YEARS
(BEGINNING WITH THE MOST CURRENT) Please complete or attach resume. We may contact employer unless you indicate otherwise. Company Name __________________________________________________________________________ May we contact this employer Yes No Contact Name _____________________________________ From ______________________ To_____________________ Phone _____________________________________________
Address ____________________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________ Type of Business _________________________________________________________________________ Describe Responsibilities ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ # of Employees Supervised ________________________
Company Name _________________________________________________________________________ May we contact this employer Yes No Contact Name ____________________________________
From ____________________ To_____________________ Phone ___________________________________________
Address ____________________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________ Type of Business ________________________________________________________________________ Describe Responsibilities ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ # of Employees Supervised ________________________
Company Name __________________________________________________________________________ May we contact this employer Yes No Contact Name _____________________________________
From ____________________ To_____________________ Phone ___________________________________________
Address ____________________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________ Type of Business _________________________________________________________________________ Describe Responsibilities ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ # of Employees Supervised ________________________
Describe any training in sales, management or retailing which will benefit you in implementing a Zen Massage franchise opportunity ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________
Page 2 of 6
PERSONAL/BUSINESS FINANCIAL STATEMENT
(YOU MAY SUBMIT YOUR OWN BALANCE SHEET/FINANCIAL STATEMENTS)
Assets
Cash on hand and in banks U.S. government securities Trade accounts and loans receivable Notes receivable – secured and unsecured Life insurance – cash surrender value Stocks and bonds – marketable and non marketable Real estate Real estate Real estate Automobiles – market value Other assets, property or investments (item below) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ TOTAL ASSETS $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________
LIABLITIES
Notes payable to banks – secured and unsecured Notes, loans, advances, accounts payable to others Credit card debt Loans against life insurance Property taxes and assessments payable Mortgages payable on real estate Liens on real estate Federal and state taxes on current income Other debts (itemize below) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ TOTAL LIABILITIES $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________
Page 3 of 6
PERSONAL/BUSINESS FINANCIAL STATEMENT cont’d.
ANNUAL SOURCES OF INCOME
Salary Bonus and commissions Dividends and interest Real estate income Business profession income Other income (itemize below) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ TOTAL ANNUAL INCOME $ ________________ $ ________________ $ ________________ $ ________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ $ __________________
NET WORTH
Total assets Less total liabilities Net worth $ ________________ $ ________________ $ ________________
BUSINESS REFERENCES
(PROVIDE AT LEAST THREE) Contact Name _____________________________________________________________________ Phone _____________________________________________________
Home Address ______________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________
Contact Name _____________________________________________________________________
Phone _____________________________________________________
Home Address ______________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________
Contact Name _____________________________________________________________________
Phone _____________________________________________________
Home Address ______________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________
Contact Name _____________________________________________________________________
Phone _____________________________________________________
Home Address ______________________________________________________________________________________________________________________________________ City, State, Zip _______________________________________________________________________________________________________________________________________
Page 4 of 6
BUSINESS DATA
How did you learn about Zen Massage Center Franchise program? ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Do you now operate or have you had experience in operating a business/franchise? ______ YES ______ NO Do you intend to devote yourself full-time to the day-to-day operation of a Zen Massage Center? ______ YES ______ NO If not explain the details about your operating plan. ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Have you (and, if applicable, any parties, 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 or deceptive practices, misappropriation of property or comparable allegations? _______ YES If yes, explain ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Have you (and, if applicable, any partners, officers, directors or shareholders) ever been adjudged bankrupt or reorganized due to insolvency, or been a principal officer of any company or a partner in any partnership that was adjudged bankrupt or reorganized due to insolvency? ______ YES If yes, explain ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Other relevant information ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ Will your franchise investment come from your own capital? Are you willing to relocate? Geographical location preference for Zen Massage franchise opportunity. First choice _______________________________________________________________________ Second choice ____________________________________________________________________ Third choice ______________________________________________________________________ What date do you plan to open your first Zen Massage Center? _______________________________________________ Please check the level of franchise operation you plan to implement _________ Single unit operation ____________ Multi unit operation _____________ Area Developer operation _______ YES _______ YES _______ NO _______ NO ______ NO ______ NO
Page 5 of 6
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION APPLICATIONS NOT SIGNED CANNOT BE PROCESSED
I hereby attest to the accuracy of the financial statements contained in this confidential Zen Massage Center application. I authorize Zen Massage Franchising, Inc. or its agents to verify the data submitted, to obtain a consumer credit report and to make such additional credit, background or character confirmations which it deems necessary or advisable. I authorize that a photocopy or facsimile of this document may be accepted with the same authority as the original Zen Massage Franchising, Inc. agrees to maintain in confidential manner and restrict the use of any information contained or obtained in connection with this application for a Zen Massage Center Franchise.
SIGNATURE OF APPLICANT _____________________________________________
DATE ______________________________________________________________
AFTER COMPLETING THE ENTIRE APPLICATION, PLEASE
EMAIL IT TO: SALES@ZENMASSAGEUSA.COM
OR
FAX TO: 704-717-5138
OR
MAIL TO: ZEN MASSAGE FRANCHISING, INC. 3436 TORINGDON WAY SUITE 103 CHARLOTTE, NC 28277
HAVE QUESTIONS?
CALL US AT 1-704-717-5123
WE ALSO ENCOURAGE YOU TO VISIT OUR WEBSITE AT WWW.ZENMASSAGEUSA..COM
PLEASE NOTE THAT COMPLETETION OF THIS APPLICATION IS NOT A FRANCHISE OFFERING.
Page 6 of 6