application

[Apply & Qualify] [ Request Sales Kit] [ Questions & Comments]

Please complete this application to qualify for a DRYCLEAN USA license.

All information contained in, and pursuant to this application, is considered confidential and will be held in the strictest confidence of DRYCLEAN USA.

PERSONAL INFORMATION
First Name :	Middle Initial:
Last Name:
Email Address:
D.O.B. :
Soc. Sec. No. :
Home Address :
City :
State :	Zip Code :
Home Phone :
Business Phone :
Employer :
Position :
Business Address:
City :
State :	Zip Code :
Annual Income :	Martial Status :
Spouse's Name :	No. of Children :
Spouse's Occupation :	No. of Dependants :
Spouse's Income :	No. of Years with Employer:
Home :	Own Rent
Make sure you	enter your complete Name and Address, Phone Numbers, and valid Email Address. This information is required to submit this application.

BUSINESS HISTORY
Are you a US Citizen?		Yes No

Have you ever been convicted of any misdemeanor and/or felony? (Other than a minor traffic violation)		Yes No

If yes, Please state details


Are you currently involved in any lawsuit or legal action, either as Plaintiff or Defendant?		Yes No

BUSINESS EXPERIENCE: (PAST TEN YEARS - List present to most recent position first)


RETAIL EXPERIENCE: Do you now, or have you ever, owned or had an interest in a retail or service-oriented business:		Yes No

If yes, Please state details


FRANCHISE INFORMATION: *Are you related to any Officer, Director, Employee or Licensee of DRYCLEAN USA License Group?*		Yes No

If yes, please state relationship & Position


Will you have any Business Partner(s)?		Yes No

To what extent will you be involved in the daily operations:	None Minimal FullTime

In the space below, please write a brief description of why you think you would be successful in our business.



*How or from whom did you learn of the DRYCLEAN USA* License Program?**



GEOGRAPHIC AREA OF INTEREST: Location Preferences:	1st Choice
	2nd Choice
	3rd Choice

ASSETS
Cash on Hand, and Restricted in Banks
U.S. Government Securities
Accounts & Loans Receivable
Notes Receivable, not Discounted
Life Insurance, Cash Surrender Value
Stocks & Bonds
Real Estate
Automobiles
Other Assets (Itemize)




Total Assets

LIABILITIES
Notes Payable to Bank
Notes Payable to Others, Unsecured
Notes Payable to Others, Secured
Loans Against Life Insurance
Accounts Payable
Interest Payable
Taxes & Assessments Payable
Mortgage Payable on Real Estate
Brokers Margin Accounts
Other Liabilities (Itemize)




Total Liabilities

ANNUAL INCOME
Salary (Excluding Bonuses)
Salary (Spouse, Excluding Bonuses)
Securities Income
Rentals
Other Income (Describe)





Total Income

ANNUAL EXPENDITURES (Excluding Ordinary Living Expenses)
Mortgage
Real Estate Payment(s)
Rent
Income Taxes
Insurance Premiums
Other (Describe/Include installment payments & other real estate)





Total Expenses

This application in no way obligates either you, or DRYCLEAN USA, in any manner.
This information has been provided for the specific purpose of obtaining a DRYCLEAN USA
license and is for DRYCLEAN USA's internal use only in rendering a decision.
The applicant(s) submitting this application expressly agree(s) that to the best of their knowledge this
application is an accurate and complete representation of their financial and operational qualifications and
background. By submitting this document, the applicant authorizes DRYCLEAN USA to investigate
their credit worthiness, including credit bureau reports.

Before submitting this form, it is recommended that you
print this page if you would like to retain a copy for your records.

Your Complete Name and Address, Phone Numbers, and valid Email Address
are required to submit this form.
Please make sure this information is complete prior to submitting.