Franchise Application

Information

First Name *

Last Name *

Email *

City *

Street Address *

State *

ZIP Code *

Daytime Phone *

Evening Phone *

Cell Phone *

Best Time to Call *

Current Occupation *

How long employed at present occupation? *

Co-Applicant's Name *

Co-Applicant's Employer *

Children *

Have you been convicted of a crime in the past 5 years? (Exclude traffic infractions) *

If so, please provide details

Will you or the co-applicant continue to work at your current place of employment after the franchise is awarded?

Self: *

Yes

Co-Applicant *

Yes

Who will operate the store? *

If other, please specify:

In what state, county and city would you like to own your own Pak Mail? *

If accepted, how soon would you anticipate opening your own Pak Mail? *

(Please note that answering no to the following questions does not automatically disqualify you.)

Are you a U.S. citizen? *

Yes

Are you a veteran of the U.S Armed Forces? *

Yes

FINANCIAL INFORMATION

ASSETS

Cash *

Stocks/Bonds *

Real Estate Market Value *

Automobile(s) *

Other *

LIABILITIES

Mortgage *

Auto Loan *

Notes Due Others *

Credit Card Balance *

Other *

NET WORTH

Net Worth (Total Assets - Total Liabilities) *

OTHER FUNDING

Do you anticipate obtaining a loan from another source to assist you in funding this franchise opportunity? *

Yes

Please note that answering yes to the following questions does not automatically disqualify you.

Loan Source

Amount

Where will the funds come from to meet the initial cash injection requirement of start-up? *

SOURCES OF INCOME

Have you ever filed for bankruptcy? *

Yes

Interest *

Alimony *

Pension *

Real Estate *

Inheritance *

Other *

If "Other", please explain:

This is not a franchise offering. A franchise offering can be made by us only in a state if we are first registered, excluded, exempted, or otherwise qualified to offer franchises in that state, and only if we provide you with an appropriate franchise disclosure document. Individualized responses or communications to you that involve either effecting or attempting to effect the sale of a franchise will be made only if we are first in compliance with state registration requirements, or are covered by an applicable state exclusion or exemption. Notice of Available Disclosure Formats We will furnish you with our franchise disclosure document in paper form, if you qualify as a franchisee prospect. The franchise disclosure document will be presented to you personally in our office, by mail or by courier to you at our cost, if you qualify as a franchisee prospect. A copy of the franchise disclosure document will be made available to you electronically in PDF format, by written request to Mary Ann Canup at [email protected] only if you qualify as a franchisee prospect. You will need to have Adobe Reader software installed on your computer to view the document and a printer to create a paper copy of the document.

I agree the information contained is true, accurate, and complete to the best of my knowledge. *

Yes