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The information you provide will assist PJ's Coffee better understand your current financial position as well as your personal and professional background. Be assured this information will be held in strict confidence and is only used for internal review by our Franchise Executives. We appreciate you taking the time to complete this in its entirety as this will help us prepare for our initial discussion regarding your interest in exploring the PJ's Coffee franchise opportunity.


Fields marked with * are mandatory.


GENERAL INFORMATION
First Name : Last Name : How did you hear about us? : Home Address : City : State / Province : *Country : Address :


FINANCIAL SNAPSHOT
Do you have access to a minimum of $150,000 in liquid capital? Liquid Capital is a readily convertible asset such as cash (non-borrowed), certificates of deposits, marketable securities, stocks, and bonds : YesNo Cash ($) : Is your net worth greater than or equal to $500,000? Net Worth is your significant assets minus your liabilities (what you owe in debts) : YesNo Net Worth ($) : Is your credit score 700 or greater? : YesNo Credit Score :


GETTING TO KNOW YOU
Where (city, state) would you like to open your PJ's? : When would you like to open your PJ's? : Have you ever declared bankruptcy? : YesNo Why are you interested in owning a PJ's? : Who else would be involved in your PJ's? : Have you ever been convicted of a felony or serious crime? : YesNo

TERMS AND CONDITIONS

The undersigned understands PJs Coffee is relying on this information in rendering its decision to award a franchise. Furthermore, the undersigned warrants the information to be true & correct and that any alterations to this information shall be made by written notice.

*I accept and agree to the above terms & conditions


SIGNATURE
Electronic Signature : Date Signed :