BLACKJACK PIZZA FRANCHISING, INC FRANCHISE APPLICATION ‘Because this franchise business requires a considerable cash investment, itis necessary to establish your net worth. Frequently, several individuals wish to franchise within the same market area. In order to properly evaluate your application, itis necessary that you fill out the form as accurately and completely as possible. This information will be held in absolute confidence and does not obligate either party. Personal Data The following information is the basis for my franchise application: Applicant Name: Date: Home Address cit Stawe Zip Code Physical _Home Telephone E-mail Address: Limitations: Citizenship Social Security Number: Date of Birt: Marital Status “Spouse's Name: Spouses Social Security Number: Spouse's Occupation: How Long: Income: No.of Dependents: Home: Rent own renting, name of Landlord Education = Cine Yar Cond High School: 123-4 College: 1-25 4 Grate Ses: 12 Narn of College 7 Degree: When Last Former Residence iftess than 2 Yous: ciy State Zip Code Bu: ess Experience Present Poston Salary ier Income: Responsibilities Business Address: Business Telephone: (Curent Busines affiliations other than occupation (Owner, Partner Officer, Direct Memberships (Business, Professional, Civic) Have you ever been selemplayed? Fos, tll us more about it Previous Business Experience: Dates (Most recent fis) Company - Address ‘Annual IncomeBLACKJACK PIZZA FRANCHISING, I FRANCHISE APPLICATION Confidential Net Worth Statement Applicant Name: ASSETS. ‘CASH IN THE FOLLOWING BANKS. (eit on ean peice) [NOTES DUE TO ME (eat Oxy Li denon pe pes) ‘Secured by Rel Estate ‘Secured by Otter Colle Unsecured (Cast) [OTHER AMOUNTS OWED TO ME Profesional Accounts Recivale Other Caisbie Amounts ‘STOCKS AND BONDS (Goa On Lint elena) Marketable Socks Othe Sik Sovings Bonds ‘Othe US. Goverment Obigations ‘Other Bonds ‘CASH SURRENDER VALUE OF LIFEINSURANCE | AUTOMOBILES. mixes) LIABILITIES NOTES PAYABLE TO BANKS (Ge itn sport ogee) Die Ter Coie 2. Duet Coles: 3. Duet [REALESTATE (Tos Only Lis do on sn as) ‘OTHER NOTES PAYABLE SECURED 1. Due To Calera: 2. Duet Collaea: ‘OTHER NOTES PAVABLELUNSECURED ue To Due To ‘TAXES OWING, Income Taxes Other Tres [LIFE INSURANCE POLICY LOANS. ‘DUE ON AUTOMOBILES OWING ON REALESTATE (inti ue on Homestead ‘Dut on Ore Residential Real Ete Homesesd (ter Residential Res Ete Commercial Real Fata Rural Real Estate OTHER ASSETS (Dect) ‘TOTAL ASSETS ANNUAL SOURCE OF INCOME ‘Sune andlor Fees Bom and Commissions Dividends nd nee Real Eat Income Busines, Profession o Ryaly Ices ‘Ober Income denis taton punt page eee) ‘TOTAL, ‘Due on Commerciat Rel Esse ‘Duc on Rua Real Ese (OTHER LIABILITIES (Deity Person Bill TOTALLIABILITIES [NET WORTH (a Ave es Tol iii) ‘TOTAL LIABILITIES AND NET WORTH CONTINGENT LIABILITIES Gaarnir Olignions ‘Legal Chins Endorser or CoMaker Obligations estes oe Contes Liens or Speci Debt Provision for Fede or Ober Tes te Linbilies ~linony, Ch Suppers Maen ie ston seat page ifne) ‘TOTAL.References Individual/Company Address Phone ‘Years Known 3 Please feel free to attach any information about yourself which will help us know you better as a person. | certify thatthe preceding information isthe true and current financial condition of the undersigned, Signe Dae | certify that the above information supplied by me, is tre and correct. I authorize release of any information deemed necessary by Blackjack Pizza Franchising, ne. to verify any and all ofthe disclosed information. I hold Blackjack Franchising, Ine, harm less for any damages arising from the verification of the information concerned herein, Siena Dae All applicant will receive consideration without regard t race, color, religion, sex or national origin, Return to: Blackjack Pizza Franchising, Inc. 11005 Dover St, #100 Westminster, CO 80021 Attention: Mike Gaston 303-426-1921 303-428-0174 Fax mgaston@blackjackpizza.com wwwblackjackpizza.comQuestionnaire: (Insert) 1 Location Preferences: First Choice Second Choice How did you lear of Blackjack Pizza? _ Do you currently own any other franchises? (Ifo, please give details) Do you have any previous restaurant experience? If'so, what type? How Long? Have you ever been adjudged bankrupt or reorganized due to insolvency either as an individual or principal office of any eorpora- tion or partner of any partnership adjudged bankrupt or reorganized due to insolvency? Yes___ No. Iso, what business? Location ‘Are you currently a party to any pending legal action? Yes__ No tyes, please explain ‘Are you applying fora franchise as a corporate or partnership? -Yes_No_ If so include a copy of articles of incorporation or articles of partnership. ‘What is your Federal Employer Tax Identification Number, if any? ‘What is your State Employer or Sales Tax Number, if any? Do you plan to devote full time to this business? Yes___No If no, what percentage of time? Do you plan to employ a fulltime manager? Do you have investor-associates in this venture? Yes___ No Name Address % Ownership %Time How will you finance this investment? Cash Loan Collateral How much ofthe franchise investment will come from your own capital?