Application Name* Phone* Email* Address* Do you have access to the funds needed to open a Chem-Dry franchise?* YesNo Are you a defendant in any lawsuits or legal action?* YesNo Are you a veteran?* YesNo Have you ever filed bankruptcy or are you in process of filing bankruptcy?* YesNo Have you ever been convicted of a felony or misdemeanor (other than traffic violations)?* YesNo Total Assets* Total Income* Total Liabilities* Your Estimated Net Worth (Total Assets plus Income minus total liabilities)* Signature* I, ____________ herby authorize ChemDry Franchise upon the execution of this consent form, to investigate the information contained in my application, and other background information, for the sole purpose of obtaining information relevant to my qualifications as independent franchisee thereof. I understand that this means I may be subject of a 'consumer report' from an outside agency, which report may contain information about my creditworthiness, credit standing, credit capacity, character, police and criminal records, general reputation, personal characteristics and mode of living, whichever are applicable. By signing below, I authorize ChemDry to obtain or cause to be obtained, a consumer report upon receipt of this form or at any time during which I am a franchisee. ChemDry is an equal opportunity company and does not discriminate against applicants with regard to race, color, gender, sexual orientation, age, religion, disability or any characteristic protected by applicable law. I understand that inquiries on this application, which ask for my address and date of birth, are for identification purposes only. I understand that age is not considered in making decisions concerning independent franchisees. I release ChemDry or its agents and any person or entity that provides information pursuant to this form any and all liabilities arising from any claims, lawsuits, or other actions in regard to the information obtained from any and all of the above-referenced sources. I further agree that the giving of any false, misleading or incomplete information will be grounds for denial or termination. I agree on my own behalf to indemnify, defend and hold harmless ChemDry, its parent, subsidiaries, affiliates, employees. Agents and customers from and against any demands, claims, liability arising from the gathering and use of any information obtained from any and all of the above-referenced sources. The above information is my true and complete legal name and all information is correct to the best of my knowledge. Δ
