Your Personal Information
First Name:
*
MI:
Last Name:
*
Email:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Home Phone:
Fax:
Mobile:
Date of Birth:
/
/
* (MM/DD/YYYY)
Gender :*
Male
Female
Highest Education Achieved:
Please Select
College Degree or higher
Some College
High School/GED
Didn't Complete High School
*
Schools Attended
Years
Grade/Degree Attained
*
*
*
Experience Level:
Please Select
CEO/Owner
Corporate Executive
Area/Regional Management
Upper-Mid Management
Mid-Lower Management
Non-Management
No Business Experience
*
Tax ID/Social Security Number:
*
Aliases:
Citizen of
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands, U.K.
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Bes Islands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Barts
St Martin
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
West Bank and Gaza
Yemen
Zambia
Zimbabwe
*
Permanent Resident of
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands, U.K.
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Bes Islands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Barts
St Martin
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
West Bank and Gaza
Yemen
Zambia
Zimbabwe
*
How did you hear about OneClick Cleaners?
*
Are you of legal age in your State? *
Yes
No
Have you ever been convicted of a felony or its equivalent? *
Yes
No
Have you ever been associated directly or indirectly with terrorist activities? *
Yes
No
A judgment was filed against or you've been involved in any litigation within last 5 years? *
Yes
No
(If yes, on a separate sheet of paper provide the following for each proceeding: names of the parties involved, date filed, court where filed and nature of the proceeding.)
(Optional) Spouse's Information (Partners must fill out a separate application)
First Name:
MI:
Last Name:
Date of Birth:
/
/
(MM/DD/YYYY)
Gender :*
Male
Female
Tax ID/Social Security Number:
Aliases:
Citizen of
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands, U.K.
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Bes Islands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Barts
St Martin
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
West Bank and Gaza
Yemen
Zambia
Zimbabwe
Permanent Resident of
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands, U.K.
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Bes Islands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Barts
St Martin
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
West Bank and Gaza
Yemen
Zambia
Zimbabwe
Are you of legal age in your State? *
Yes
No
Have you ever been convicted of a felony or its equivalent? *
Yes
No
Have you ever been associated directly or indirectly with terrorist activities? *
Yes
No
A judgment was filed against or you've been involved in any litigation within last 5 years? *
Yes
No
(If yes, on a separate sheet of paper provide the following for each proceeding: names of the parties involved, date filed, court where filed and nature of the proceeding.)
Business Information
Self Employed
Employed By
*
Years:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Phone:
*
Type of Business:
*
Title:
Describe Position:
May we contact you at work? *
Yes
No
List all businesses that you have an ownership interest:
1.
2.
3.
Financial Information (Please list figures in US dollars)
Current Annual Job Income:
*
Other Sources Annual Income:
Please explain other sources income:
Personal Bank Name(s)
Branch
Address
Individual Liquid Assets (Cash, Stocks, etc.):
A.
*
Individual Fixed Assets (Home, Car, etc.):
B.
*
Individual Total Assets:
C.
*
(A + B)
Individual Liabilities (Mortgages, Loans, etc.):
D.
*
Your Individual Total Net Worth:
(Excluding any financing listed below.)
E.
*
(C - D)
Would this business be your sole income source? *
Yes
No
Is there other financing not included in "E" above? *
Yes
No
If yes, how much financing is available?
Currency Type:
References (Excluding Relatives)
Name
Phone
Address
*
*
*
Partners (All partners must fill out separate applications)
First Name
MI Last Name
Gender
% Ownership
M
F
Active
Silent
M
F
Active
Silent
M
F
Active
Silent
M
F
Active
Silent
Partner's financial information should be included in their separate application(s).
Franchise Operations
If qualified, when will you invest in a franchise?
Immediately
Within next 6 months
Within next 12 months
*
How involved will you be in operating the franchise?
Please Select
Not Involved at All
Somewhat Involved
Completely Involved
*
Estimated training date should you choose to invest:
/
/
* (MM/DD/YYYY)
Disclaimer
I understand that the granting of a franchise is at the sole discretion of the OneClick Cleaners Inc.
I understand that any information I receive from the Franchisor or from any employee, agent or franchisee of the Franchisor or its affiliate is highly confidential ("Confidential Information"), has been developed with a great deal of effort and expense to the Franchisor, and is being made available to me solely because of this application. I agree that I shall treat and maintain all Confidential Information as confidential, and I shall not, at any time, without the express written consent of the Franchisor, disclose, publish, or divulge any Confidential Information to any person, firm, corporation or other entity, or use any Confidential Information, directly or indirectly, for my own benefit or the benefit of any person, firm, corporation or other entity, other than for the benefit of the Franchisor.
I authorize the Franchisor or its designee to procure an investigative consumer report, a general background search and an investigation in accordance with anti-terrorism legislation, such as the USA Patriot Act and Executive Order 13224 enacted by the US Government (collectively referred to as "Investigations"). I understand that these Investigations may reveal information about my background, character, general reputation, mode of living, association with other individuals or entities, creditworthiness, litigation history and job performance (collectively referred to as "Investigation Data"). I understand that, upon written request, within a reasonable period of time, I am entitled to additional information concerning the nature and scope of these Investigations. I hereby release any representative of the Franchisor or its affiliate, a credit bureau, security consultant or other investigative service provider selected by the Franchisor, its affiliates, officers, agents, employees, and/or servants (collectively referred to as the "Investigator") from any liability arising from the preparation of these Investigations. This authorization for release of information includes but is not limited to matters of opinion relating to Investigation Data. I authorize all persons, schools, companies, corporations, credit bureaus, law enforcement agencies or other investigative service providers to release such information without restriction or qualification to the Investigator. I voluntarily waive all recourse and release them from liability for complying with this authorization. This authorization/release shall apply to this as well as any future request for these Investigations by the above named individuals or entities. I authorize that a photocopy or facsimile of this release be considered as valid as the original.
US, PUERTO RICO AND CANADA **In order to purchase a OneClick Cleaners® franchise in the US, the franchisee must be a citizen or permanent resident of the US. In order to purchase a OneClick Cleaners® franchise in Canada, the franchisee must be a citizen or permanent resident of Canada. I agree that I will settle any and all previously unasserted claims, disputes or controversies arising out of or relating to my application or candidacy for the grant of a OneClick Cleaners® franchise from Franchisor, pursuant to the laws of New York, USA* and by binding arbitration only. The arbitration shall be administered by an arbitration agency, such as the American Arbitration Association ("AAA") or the American Dispute Resolution Center, in accordance with its administrative rules including, as applicable, the Commercial Rules of the AAA and under the Expedited Procedures of such rules or under the Optional Rules For Emergency Measures of Protection of the AAA. I agree that arbitration will be held in New York, New York, conducted in English and decided by a single arbitrator.
Everything that I have stated in this application is true and I understand that the information provided by me will be relied upon by the Franchisor. In accordance with anti-terrorist legislation, I understand that I will not be approved to purchase a franchise if I have ever been a suspected terrorist or associated directly or indirectly with terrorist activities. I read, understand, and agree to all of the above.
Comments & Requested Territory
*
Signatures
I have read the above disclaimer .
Type name to indicate consent. Signature required at time of sale.
Applicant's Typed Name:
*
Date: 05/20/2012
Spouse's Typed Name:
Date: 05/20/2012
Code:
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