APPLICATION FOR A FRANCHISE

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					APPLICATION FOR A FRANCHISE
CONFIDENTIAL QUESTIONNAIRE

PREAMBLE
Subject to territories being available, The Drain Surgeon is in a position to offer you two tried and tested franchise options: The Drain Surgeon Franchising Africa (Pty) Ltd offers franchises to carry out emergency plumbing repair services (No need to be a plumber). The Electro Clinic (Pty) Ltd offers franchises to carry out emergency electrical services (Must be a qualified electrician). Both franchises apply the same successful business system, and are subject to certain criteria being met, the two franchises can be combined. This creates significant synergies for franchisees. Please tick your preference: I am specifically interested in The Drain Surgeon Plumbing Franchise I am specifically interested in The Electro Clinic (Must be a qualified electrician). I am prepared to look at either option Completion of this Confidential Questionnaire does not obligate The Drain Surgeon Group nor the applicant in any way; please refer to the “Declaration” on page 8 in this regard.

PERSONAL INFORMATION
Date: Surname: Postal Address: Code: ID Number: First Name(s):

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Residential Address: Code: Home Tel no: Cell no: Residence (please tick): Date of birth: Weight: Marital Status: married single Owned Rented Height: Nationality: divorced separated widowed Boarding Work Tel no:

Number of children:

Other Dependents:

If related to anyone in our employment state his/her name and branch:

Referred to us by: Former employers, (list 2 employers, most recent first):
( Month, Year ) Date Name and Address of Employer Received Salary Position Held Reason for leaving

From: To: From: To:

References: (Names of three people [unrelated] whom you have known for at least one year): Name: Name: Tel no: Tel no:

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Name: For Reference Purposes, we will phone them:

Tel no: YES NO If no, REASON:

If married does spouse work: Spouse’s annual income R:

If “yes” the position held: Would spouse join in the business:

YOUR EDUCATION
Level of Institution Primary High University Trade College, Business School Or Correspondence College Name, Location Years Attended Date Graduated Subjects Studied

GENERAL INFORMATION:
Do you have a budget? Yes No Yes No Do you have an organised method of saving or investing?

Please organise the heading below in order of importance to your: Social Life – Spiritual Life – Mental Life – Physical Life – Financial Life. 1. 3. 5. 2. 4: 6:

QUESTIONNAIRE
In order for both an individual and a company to grow, they must have common goals and beliefs. The following questionnaire will help determine your needs and ascertain whether or not they run

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parallel to our needs as an organisation. For your own benefit, please be frank with your answers – you cannot build a successful business on imaginary foundations. 1. Briefly outline your present job or business duties:

2. If you could have any job or position you wanted, what would you really want to do?

3: What qualities do you have that you think would be valuable if you became part of The Drain Surgeon/Electro Clinic?

4. How much time out of every 24 hours do you dedicate to: Activity Your occupation Sleeping Playing and relaxation Hours Waste Activity Hours

Self – improvement Other – explain below Family

Acquiring useful knowledge

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5. If you could live life again, what changes would you make?

6. What do you think is likely to make a difference between success and failure in any business?

7. What do you think has been your greatest accomplishment to date in life?

8. What has been your greatest disappointment?

9. What have you done in the past year to improve yourself?

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10. How do visualise your franchise of The Drain Surgeon/Electro Clinic?

11. How much money would you need to earn as a franchisee of The Drain Surgeon/Electro Clinic considering your minimum financial requirements especially regarding the 1st year? First year: Third year: Second year:

12. How does your spouse feel about your interest in becoming a franchisee of The Drain Surgeon/Electro Clinic?

13. What do you consider to be your greatest strengths…

…and your weaknesses?

14. Which one of our services interests you the most, and why?

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15. What do people most often criticise you for?

16. What qualities in other people do you dislike the most?

17. What factors in your past have contributed most to your own development?

18. What factors have prevented you from moving ahead more quickly?

19. What else do you think The Drain Surgeon/Electro Clinic should know about you to understand you better?

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21. If accepted, when could training be scheduled? 22. Who among your acquaintances Encourages you the most? Cautions you the most? Discourages you the most?

23. Who do you consider the most successful person you have ever met and why?

PERSONAL FINANCIAL INFORMATION
Name of your bank: Contact person: Type of account: Type of account: Branch: Telephone no: Account no: Account no:

Other account details and / or credit card details:

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Personal Balance Sheet 01 02 03 04 05 06 07 08 09 10 A 11 12 13 14 15 16 B Cash in bank Savings Loans granted to others* Property owned* Shares in listed companies* Private motor vehicle(s) Value of other assets Market value of own business (if applicable)

Assets in Rands

Liabilities in Rands

Total assets

R

Bank loan(s)*

Bond(s) on property* HP on motors* HP other*

Other liabilities* Total Liabilities R

Your net Worth (equals A minus B)

R

*Please provide details on top of next page, or use a separate sheet of paper. Details of items marked* (previous page):

YOUR PLANS REGARDING YOUR FRANCHISE:
Cash available for investment (own resources or “soft loan” from family, before borrowings):

State minimum drawings per month during first year:

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Are you willing to relocate (state either yes or reluctant or number as applicable): If you answered “yes”, please state preferred area(s):

Additional comments you wish to make (optional):

Declaration by applicant I have completed the above questionnaire to my best knowledge and ability with the intention to be considered for a franchisee of The Drain Surgeon/Electro Clinic. I understand that at this point I am not binding myself in any way whatsoever. I further understand that, should I be accepted as a franchisee based on the information provided to me, and should it become known to The Drain Surgeon at a later date that the information that has been provided is false, or that I have withheld important facts, this may cause termination of any agreement entered into The Drain Surgeon Franchising Africa (Pty) Ltd and/or The Electro Clinic (Pty) Ltd and myself. Date: Signature:

Please return to: The Drain Surgeon/Electro Clinic, Franchise Division P. O. Box 912 – 100 Silverton 0127 Pretoria Republic of South Africa Telephone: (027 12) 342 – 1860 Fax: (012) 342 - 1475

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Description: APPLICATION FOR A FRANCHISE