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INFORMATION

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									                                                    Barter Americas, Inc
                                                   113 22nd Street, Suite 1
                                                    Bentonville, AR 72712
                                                       Phone 1-866-419-1430
                                                        Fax 1-479-927-1803


                                                       INFORMATION

Name:                                                      Social Security #:
Address:                                                   City:                           State:                  Zip Code:
Day Time Phone:                                            Evening Phone:
Email Address:                                             Driver’s License #:                                     State:
Spouse’s Name:                                  Spouse’s Occupation:                                 # Dependants:
         THIS FORM IS THE PRESENTATION OF PERSONAL INFORMATION FOR THE CONFIDENTIAL USE OF THE FRANCHISE DEVELOPMENT DEPARTMENT.
                          THE COMPLETION OF THIS FORM WILL ENABLE US TO BEGIN THE QUALIFICATION PROCESS QUICKLY.




                                               EMPLOYMENT HISTORY
Company:                                                   City:                                                   State:
Phone:                                From:                To:                             Position:


Company:                                                   City:                                                   State:
Phone:                                From:                To:                             Position:


Company:                                                   City:                                                   State:
Phone:                                From:                To:                             Position:



                                                          EDUCATION

Grades 1-12          Last School:                          City:                                                   State:

College 1        2       3       4              College Name:
Major:                                                     City:                                                   State:
Degree(s) Achieved:
Military Service:                     Branch:                         Years:                         Honorably Discharged:
                                   PERSONAL INFORMATION
Have you ever owned a franchise?
If “Yes”, which franchise:
Describe your experience:
Are you exploring other franchise opportunities?
What percentage (%) of your time do you expect to donate to the franchise?
Do you have or do you have access to the funds necessary to invest in this franchise?
Do you regard BANX as an investment, career, or speculation?
Would you employ a full time manager?
If selected, when would you begin operating your franchise?
What market place are you interested in?
Have bankruptcy proceedings ever been held against you?
If “Yes”, please explain:
Are you now, or have you ever been, party to any suits or civil actions?
If “Yes”, please explain:
Have you ever been convicted of a crime other than minor traffic accidents?
If “Yes”, please explain:


                              PERSONAL CREDIT INFORMATION
Personal Bank:                                       City:                        State:
Account #:                           Phone:                         Contact:


Personal Bank:                                       City:                        State:
Account #:                           Phone:                         Contact:



                                MAJOR CREDIT INFORMATION
Credit Name:                                                 Date Opened:
Address:                             City:                          State:
High Balance:                 Current Balance:               Monthly Payment:
Credit Name:                                                 Date Opened:
Address:                             City:                          State:
High Balance:                 Current Balance:               Monthly Payment:
                              PERSONAL FINANCIAL STATEMENT
                 Please do not leave any questions unanswered. If none, reply n/a.




Assets:                           Value      Liabilities:                            Value
Cash on hand                      $          Notes payable to banks - secured        $
Mutual funds, stocks, bonds       $          Notes payable to banks - unsecured      $
IRA's and 401(k)s                 $          Notes payable to others - unsecured     $
Accounts and Notes Receivable     $          Amounts payable to others - unsecured   $
Non-marketable securities         $          Accounts and Bills due                  $
Real Estate - Primary Residence $            Unpaid income tax                       $
Real Estate - Investment Property $                                                  $
Automobiles (non-leased)          $          Real Estate Mortgages Payable           $
 1. Year         Make             $          Other debt (explain)                    $
 2. Year         Make             $          Other debt (explain)                    $
Other Assets                      $          Total Liabilities                       $
Total Assets                      $          Net Worth (Assets minus Liabilities)    $


                          ANNUAL SOURCES OF INCOME
                          Salary                 $
                          Bonus and Commissions  $
                          Other                  $
                          Total                  $


                              ANNUAL SOURCES OF INCOME (SPOUSE)
                           Salary                            $
                           Bonus and Commissions             $
                           Other                             $
                           Total                             $

								
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