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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 :