Personal Information:
First Name:	Last Name:	E-mail:
Address:	City:	State:
Zip Code:	County:	# of Years there:
Business Phone:	Home Phone:	Mobile Phone:
Best Time to call:	Marital Status: Choose One Single Married Divorced	Spouse's Name:
# of Dependents:	Dependents Ages:	How did you hear of us? Choose One Magazine Direct Mail Television Radio Internet Search Word of Mouth Other
Education Highest Degree/Equivalency: School/Instution Name: Major Field of Study:	Applicant	Spouse/Domestic Partner
Business Experience: (Please list company name, type of business, position held, dates position held and your most significant accomplishments.)
Present/Most Recent Experience:
Company Name:	Type of Business:	Position Held:
From (Date):	To (Date):	Reason for leaving:
Significant Accomplishments:
Previous Experience:
Company Name:	Type of Business:	Position Held:
From (Date):	To (Date):	Reason for leaving:
Significant Accomplishments:
Previous Experience:
Company Name:	Type of Business:	Position Held:
From (Date):	To (Date):	Reason for leaving:
Significant Accomplishments:
Have you ever owned a business?	Yes No
If yes, what type of business?
Other Business Affiliations: (Officer, Director, Partner, etc.)
Business & Management Goals
Do you plan to devote full time to this business venture?		Yes No
Will your spouse be active in the franchise?		Yes No
Do you plan to have equal partners?		Yes No
If Yes, please identify all partners:
Name:	Address:	Phone #:
	Active in Franchise?	Yes No
Name:	Address:	Phone #:
	Active in Franchise?	Yes No
Name:	Address:	Phone #:
	Active in Franchise?	Yes No
Preliminary Financial Disclosure:
Assets:	Liabilities:	Net Worth:
Unencumbered Liquid Assets:	Equity in Personal Residence:	Equity in Other Real Estate:
Social Security Number: Note: a U.S. Social Security Number is not required to complete this form. ASSETS (Details) LIABILITIES (Details) Cash on Hand: Savings:     Notes Receivable: Real Estate Value1:     Non-Current Assets: Semi-liquid Investments3: Sellable Personal Property5: Annuities/Residual Income6: Other Assets: TOTAL: Private Cash Debt:     Taxes Payable: Notes Payable: Real Estate Debt1: Installment Debt2: Property Liens:     Loans Against Investments4:     Other Liabilities: TOTAL:   NET WORTH: Complete Schedule 1 to determine this value. Non-Real Estate related (i.e. Credit cards, vehicles, student loans, etc.) Mutual Funds, Marketable Securities, Life Insurance, etc. 401K Loans, Loans on life insurance, etc. Recreational vehicles, art, jewelry, etc. Mortgages held, Trusts, etc.
Other Information:
Franchise Location Preferences City State/Province ZIP/Postal Code 1st Choice 2nd Choice 3rd Choice   Would you consider acquiring an existing PuroClean location (if available)? Yes No
Why do you believe you can successfully operate a PuroClean franchise?
How will the PuroClean franchise opportunity help you in achieving your business and personal goals?
Additional information or comments that you might like to share with us in evaluating your Request for Consideration:
By completing and submitting this Request for Consideration you will be authorizing PuroSystems, Inc., or its agents to verify the information contained in the Request for Consideration. By completing and submitting the Request for Consideration you are indicating that you have the authority to do so. PuroSystems, Inc. Inc. reserves the right not to verify, in whole or in part, the information contained in the Request for Consideration and to rely on the honest answers of the person completing the form. You further agree that the information furnished herein is true and correct and you authorize us or our agent to investigate your personal credit by reviewing a credit bureau report on you and/or the balances in any checking, savings or investment accounts.