LICENSING APPLICATION

PERSONAL INFORMATION

First Name: _____________________________________

Last Name: _____________________________________

Home Phone:___________________________

Social Security#:_________________________________

Address:__________________________________________

City: ______________________State:_____ Zip:__________

Previous address for the past five years:

_________________________________________________

City: ______________________State:_____ Zip:__________

Date of Birth: ______________ Marital Status:___________

Spouses Name:____________________________________

Spouses Social Security #:___________________________

Names of children:

(1)________________________Age:________

(2)________________________Age:________

(3)________________________Age:________

Total Number of Dependents: ______________

Date of last Physical exam:____/____/____

Reason for last Physical exam:__________________________

_________________________________________________

Have you ever been convicted of anything other than minor traffic violations? _________________________________________________
Has any judgement ever been entered against you or your company or your employer where you were one of the litigants? _________________________________________________
Are you involved in pending litigation ?
_________________________________________________

Have you or your spouse ever declared personal bankruptcy ?
(__) YES     (__) NO
If Yes please explain:
_________________________________________________

Of which Country are you a citizen ?_____________________

EDUCATION
Last year of school completed ?________________________
Degree:__________________________________________
Name of college and/or postgraduate school :
________________________________________________
Please describe any training in sales, management or retailing:
________________________________________________

BUSINESS EXPERIENCE

Company Name: __________________________________

Work Phone:(_____)___________________
Business Address:_________________________________
City:_____________________State:_____ Zip:__________
Title: ___________________________________________

Number of employees supervised ?:___________
Please describe duties and responsibilities:
_______________________________________________

Date employed ?:___/___/___
May we contact you at work ?:(__) YES     (__) NO

Previous business experience ( Please give exact names, addresses and dates. List most recent first)

1. Date employed from:___/___/___ to: ___/___/___
Position:________________________________________
Company Name:_________________________________
Type of business:_________________________________
Supervisor’s name:________________________________
Reason for leaving:________________________________
Address:________________________________________
City:_____________________State:_____ Zip:__________
Responsibilities:___________________________________

2. Date employed from:___/___/___ to: ___/___/___
Position:________________________________________
Company Name:_________________________________
Type of business:_________________________________
Supervisor’s name:________________________________
Reason for leaving:________________________________
Address:________________________________________
City:_____________________State:_____ Zip:__________
Responsibilities:___________________________________

3. Date employed from:___/___/___ to: ___/___/___
Position:________________________________________
Company Name:_________________________________
Type of business:_________________________________
Supervisor’s name:________________________________
Reason for leaving:________________________________
Address:________________________________________
City:_____________________State:_____ Zip:__________
Responsibilities:___________________________________

Have you ever owned your own business or franchise? (__) YES      (__) NO
If so, please explain:_______________________________
______________________________________________
______________________________________________
Have you ever had a business failure? (__) YES     (__) NO
If so, please explain:______________________________
_____________________________________________

PERSONAL FINANCIAL STATEMENT
INCOME STATEMENT FOR TWELVE(12) MONTH PERIOD ENDING

Please provide details on the following asset verification schedules(schedule numbers in parenthesis)

Please give names of banks or finance companies where accounts are carried or where credit can be obtained or verified.

1. Bank name:____________________________________

Address:_________________________________________

City:____________________ State:____ Zip:___________
Highest extended credit:$______________
Purpose:________________________________________

2. Bank name:____________________________________

Address:_________________________________________

City:____________________ State:____ Zip:___________
Highest extended credit:$______________
Purpose:________________________________________

3. Bank name:____________________________________

Address:_________________________________________

City:____________________ State:____ Zip:___________
Highest extended credit:$______________
Purpose:________________________________________

Applicant’s Signature:______________________________
Date ___/___/___

Spouse’s Signature:________________________________
Date ___/___/___

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