First Name *

Last Name *

Email *

Phone *

Address *

Home Ownership *

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Years at This Address *

Are you a healthcare provider? *

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Current Occupation *

Years in Current Occupation *

Highest Level of Education *

Birthdate *

Best Time to Talk (CT) *

Have You Ever Been Convicted of a Felony? *

Will this be a Business Partnership? *

Marital Status *

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If Married, Will Your Spouse Participate in the Business?

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Spouse Name

Spouse Email

Spouse Occupation

Spouse Length in Occupation

Spouse Income

Business Experience

Company Name (if self employed, type "self") *

Position *

Start Date *

End Date *

Annual Income *

Previous Company

Company Name *

Position *

Start Date *

End Date *

Annual Income *

Business/Management Goals & Objectives

Is your objective to supplement, transition, replace current income, invest, or be actively involved? Please explain below. *

Number of Developments Interested *

Single Location
Two Locations
Over Two Locations
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How long have you been looking at business opportunities?

What other businesses are you considering? *

How did you hear about us? *

I'm a Current Patient
Online Franchise Searches
Open House / Grand Opening
Print Advertising or PR
Seminar / Trade Show
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What specifically interests you about this franchise? *

On a scale of 1 - 10, with 10 being the highest, how committed are you to owning your own business? *

What is your timeline for starting your own business? (In months) *

Why do you believe you can successfully operate and manage with our franchise? *

Assets

Cash in Savings

Cash in Checking

Real Estate (Home Value)

Other Real Estate

Cash Surrender in Life Insurance

Qualified Plan Assets - Stocks/Bonds

IRA's/401K

Business Assets

Appraised Collectable Assets

Other Assets

Total Assets (sum of assets) *

Liabilities

Notes Payable to Banks

Notes Payment to Finance Companies

Real Estate Mortgage Indebtedness

Automobile(s) Indebtedness

Owed on Life Insurance

Charge Accounts

Credit Cards

Taxes Payable

Other Liabilities

Total Liabilities (sum of liabilities) *

Net Worth

Net Worth (Total Assets minus Total Liabilities) *

What amount of money do you feel comfortable Investing? *

Liquid Capital *

Credit Score *

Have you ever filed for bankruptcy? *

If yes, please explain

On a scale of 1 - 10, with 10 being the highest, how committed are you to moving forward with this franchise? *

Disclosure Statement

I will not divulge or use any information of whatever kind used in connection with Performance Medical Clinic, without their consent. By submitting this form, you are agreeing to receive emails and/or text messages from us.

Full Name *

Today's Date *