Applicant’s Name

APPLICATION FOR A FRANCHISE LISENCE

PT. Deux Essential

CONFIDENTIAL

This form, when completed, is an essential part of our consideration in granting a franchise. Please
print or type and give specific answers to all questions. All answers are held in confidence. The
completion of this form places no continuing obligation on PT. Deux Essential or on the applicant.

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Mr./Mrs./Ms. Date of Birth(date/month/year) NID KTP

Address City State/Zip Code Country

Home Phone Mobile Phone Business Phone May we contact you at your business phone?

Fax E-mail

Country of Citizenship

PERSONAL INFORMATION

EDUCATION
Last year of school completed Name of college and/or post graduate school Degree

Describe any training in sales, management or retailing

BUSINESS EXPERIENCE
1. Company Position Percentage owned Years in operation

Type of Company Address

Are you still involved? Describe duties, responsibilities, and number of employees supervised

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2. Company Position Percentage owned Years in operation

Type of Company Address

Are you still involved? Describe duties, responsibilities, and number of employees supervised

3. Company Position Percentage owned Years in operation

Type of Company Address

Are you still involved? Describe duties, responsibilities, and number of employees supervised

Have you or any business entity in which you have owned an interest been involved in bankruptcy, insolvency proceedings or
compromise with creditors? If yes, please explain:

Have you ever owned or do you now own a franchised food operation? If yes, please describe

Will you devote your full time to the CALAIS franchising business? If no, indicate how you will divide your time and whom you plan on
to assign full- time management of the business.

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FINANCIAL INFORMATION
Please attach financial statement detailing the following information and sign & date. Additionally, if you are
submitting this application with a partner, you must also provide your partner’s financial information.

Annual Income General Information

Salary $ Are you a co-signer, guarantor or endorser to
anyone else’s obligation? Yes No
Spouse’s Salary $
If yes, explain
Bonus and Commissions $

Interest and Dividends $

Other Income (Itemize) List any contingent liabilities not listed above
including leases
_________________________ $

_________________________ $

TOTAL $

I hereby acknowledge that the information contained herein is complete and accurate. I authorize
PT. Deux Essential or its authorized agent(s), to make a complete credit/character check where, and
in the manner in which, it deems necessary. I understand that this is for the purpose of general
information and is in no way binding upon PT. Deux Essential or the undersigned.

Printed Name: _______________________________________

Signature: ___________________________________________

Title: _______________________________________________

Company: ___________________________________________

Date: ____ / ____ / ___

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