First Name

Last Name

Email Address

Date of Birth

Phone Number

Best Time to Call

Address

City

State

Zip Code

How long at this address?

Marital Status Marital Status Single Married Divorced

Spouse's Name

Spouse's Employer

Spouse's Annual Salary

Children living with you (names and ages)

Do you have two or more years of outside sales experience? Do you have two or more years of outside sales experience? Yes No

If yes, please describe

Reference #1

Phone Number

Reference #2

Phone Number

Have you ever owned your own business or been a partner in a business? Have you ever owned your own business or been a partner in a business? Yes No

Business Name

Type of Business

How long did you own this business?

Current Status Current Status Still own Sold Closed

Are you currently employed? Are you currently employed? Yes No

Most Recent Employer

City/State

Job Title

Date Started

Annual Salary

Phone Number

Responsibilities

May we contact your current employer? May we contact your current employer? Yes No

Were you previously employed in a sales related positon? Were you previously employed in a sales related positon? Yes No

Employer

City/State

Job Title

Dates Employed

Annual Income

Phone Number

Responsibilities

Highest level of education completed? Highest level of education completed? Some High School Diploma/GED Some College Associate’s Degree Bachelor’s Degree Master’s Degree Doctorate/Ph.D

Are you now, or have you ever been party to any lawsuit – either as defendant or plaintiff? Are you now, or have you ever been party to any lawsuit – either as defendant or plaintiff? Yes No

Have you ever been convicted of any offense (other than a minor traffic citation)? Have you ever been convicted of any offense (other than a minor traffic citation)? Yes No

If so, please explain

Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No

If so, please explain

Have you ever filed bankruptcy? Have you ever filed bankruptcy? Yes No

Date filed

Background Check Background Check I understand that a background check will be performed before I am able to operate a Town Money Saver franchise.

Did you speak to a Town Money Saver franchisee or sales representative about the opportunity? Did you speak to a Town Money Saver franchisee or sales representative about the opportunity? Yes No

Name of contact (if yes)

Why do you want to own your own business?

Will this be your full-time occupation? Will this be your full-time occupation? Yes No

When would you want to start your business?

Will you have a partner or family member involved? Will you have a partner or family member involved? Yes No

Name (if yes)

Desired territory/market

Please rate your Sales Skills Please rate your Sales Skills 1 (No skill) 2 3 4 5 (Highly skilled)

Please rate your Creativity Please rate your Creativity 1 (No skill) 2 3 4 5 (Highly skilled)

Please rate your Personal Networking Please rate your Personal Networking 1 (No skill) 2 3 4 5 (Highly skilled)

Please rate your Financial Management Please rate your Financial Management 1 (No skill) 2 3 4 5 (Highly skilled)

Please rate your Business Communication Please rate your Business Communication 1 (No skill) 2 3 4 5 (Highly skilled)

Please rate your Computer Skills Please rate your Computer Skills 1 (No skill) 2 3 4 5 (Highly skilled)

Disclaimer Disclaimer I affirm that this application is an accurate and complete representation of my financial and operational qualifications and background. Town Money Saver will hold all information confidential and solely for the use in evaluating my consideration for a franchise. Any material misrepresentation provided in this document shall be adequate grounds for Town Money Saver to rescind any agreements entered into based upon such data. In the event of a material change in the data contained herein, I will promptly advise Town Money Saver of it. I certify that the information supplied by me in this questionnaire is true and correct.

Date