Confidential
Please complete and fax back to
ANGELA BENNETT
at
905-826-2105
Name: ____________________________________________________
Address: ____________________________________________________
____________________________________________________
____________________________________________________
Telephone: home: _________________ business: ____________________
Cell: _________________ fax: _________________________
Email:
______________________________________________
Marital Status:
__________________ Name of
Spouse:
__________________
Number of Children:
_____________ Ages:
__________________________
Business Experience:
Please list most recent employment
first:
No.
of
COMPANY ADDRESS POSITION YEARS
When will you be available to
open the business?
______________________________
Solicitor’s Name &
Telephone Number: _____________________________________
Will you work in the business
full time? _____________ Part-time: ______________
If part-time, please explain
why: ____________________________________________
Will you have a partner? _________________________________________________
Will he/she be active in the
business?
_______________________________________
Have you ever been convicted of a felony or misdemeanor (other than
a minor traffic violation) or are you currently involved in a criminal
proceeding?
Yes: ____________ No: ______________. If “Yes” please explain:
Details:
_______________________________________________________________________
What level of income do you expect to earn from your business? _________________
PERSONAL FINANCIAL STATEMENT:
Present annual income from all sources:
Salaries, Wages: $_______________________
Bonus, Commissions: $_______________________
Dividends, Interest: $_______________________
Real Estate income: $_______________________
Business Profits: $_______________________
Notes/accounts receivable: $_______________________
Other income, specify source: $_______________________
TOTAL: $_______________________
NET WORTH:
Cash on hand in Banks: $_______________________
Securities: $_______________________
Bonds/Notes: $_______________________
Notes/accounts receivable: $_______________________
Vested Profit Sharing: $_______________________
Real Estate: Market Value: $_______________________
Life Insurance, value: $_______________________
Business interests, value: $_______________________
Automobiles/vehicles value: $_______________________
Other: $_______________________
Total Assets: $_______________________
LIABILITIES
Loans payable (friends,
etc) $_______________________
Unpaid income
taxes due: $_______________________
Other taxes due: $_______________________
Insurance Policy
loans: $_______________________
Credit card
debts: $_______________________
Real Estate
Mortgages due: $_______________________
Other debts and
obligations: $_______________________
Alimony, child
support etc. $_______________________
Loan guarantor,
endorser etc. $_______________________
Total
Liabilities: $_______________________ Net Worth: $________________
BUSINESS
REFERENCES:
Name, Position
(Company), Telephone number:
BANK REFERENCES:
(Names of banks, finance companies etc. where accounts are and
credit references can be obtained)
Name, Address Credit
allowed Purpose
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Note the items you would convert
to cash, if necessary, to meet the initial cash requirements of INTERNATIONAL
NEWS.
INVESTMENT AND WORKING CAPITAL
AVAILABLE:
$50,000 ___________________ $75,000 __________________ $100,000 ________________
More: $______________________
This information will be treated
as strictly confidential. The undersigned
certifies that the information contained herein is accurate and authorizes
International News to contact those listed, as references should they wish to
do so.
Signature: _________________________________________ date: ________________________