Personal Information
Mr. Mrs. Ms.
First Name
Middle Name
Last Name
Current Address
City
State
Zip
Previous Address
City
State
Zip
Home Phone
Business Phone
Cell Phone
E-Mail
Date of Birth (yyyy/mm/dd)
Education
Name, City / State
Years
Level Completed
Major / Course
High School
College / University
Other
Business Information
Area Desired (1st Choice)
Area Desired (2nd Choice)
Are you willing to relocate?
Yes No
If yes, where?
Date when you will be ready to invest
Have you had previous restaurant experience?
Yes No
If yes, please describe
Will you devote your full time
Yes No
If no, please detail how you plan on dividing your time, and how the business will be managed in your absence.
Type of Ownership
Sole Proprietorship Legal Partnership Corporation
Name of Entity
Shareholders / Partners
Social Security Number Ownership (% )
Please Note: All partners must complete a separate questionnaire.
Business Experience
Present Employer
Position
Present Employer Address
Employer City
Employer State
Employer Zip Code
List Job Description and Duties:
May we contact your present employer?
Yes No
If no, why?
Past Employment
Company
Position
Annual Salary
Address
Type of Business
Employment Dates
Company
Position
Annual Salary
Address
Type of Business
Employment Dates
Have you ever worked for LaRosa's Pizzerias?
Yes No
If yes, where and when?
Business References (Please name three persons who have known you at lesat 5 years)
Name
Address
Occupation
Phone
Financial Information
How will you finance this business?
Cash $
Do you currently have a source of financing?
Yes No
If yes, please indicate source and
Would this business be your sole source of income?
Yes No
If no, state other sources of income:
Do you own an interest in any other business or investment?
Yes No
If yes, please describe:
Do you owe any money under a judgment or tax claim?
Yes No
If yes, please describe:
Are you a defendant in any lawsuits?
Yes No
If yes, please describe:
Have you ever filed bankruptcy?
Yes No
If yes, please describe:
Financial Statement (Assets)
Cash (Including Money Market Funds)
$
Accounts & Loans Receivable
$
Notes Receivable
$
Life Insurance (cash surrender value)
$
Stocks and Bonds
$
401(k), Pension Plan, Retirement
$
Real Estate (Market Value) (Home)
$
Real Estate 2
$
Real Estate 3
$
Other Assets (Auto)
$
Other Assets
$
Other Assets
$
Total Assets $
Financial Statement (Liabilities)
Notes Payable to Banks
$
Notes Payable to Others
$
Loans Against Life Insurance
$
Accounts Payable
$
Interest Payable
$
Loans against 401(k)
$
Mortgages (Home)
$
Mortgage 2
$
Mortgage 3
$
Other (Auto)
$
Other Liabilities 2
$
Other Liabilities 3
$
Total Liabilities $
Net Worth (Total Assets minus Total Liabilties) $
(Please Note: To qualify for a LaRosa's franchise, you will need access to a minimum of $2,000,000 in capital)
List financial institutions / banks where accounts are carried:
Name
Address
Account Number
Please use this space to provide us with any additional information which may assist us in evaluating your qualifications for a LaRosa's Pizzeria:
Personal Information Authorization
As part of our review of your questionnaire, LaRosa's will obtain a credit report and investigative consumer report on you from a consumer reporting agency. By submitting this questionnaire, you acknowledge and agree to LaRosa's obtaining your credit report and investigative consumer report. You acknowledge and understand that this questionnaire in no way entitles you to any rights or benefits, including without limitation, the grant of any franchise rights for a LaRosa's pizzeria restaurant.
Please type in your full name, as it will represent your signature and agreement to the information above:
Please type in the date, as it will represent the date you fill out this:
(mm/dd/yyyy)
