The
following Information is the basis for my Trademark Licensing Application. The submission
of this application does not obligate Quickly Corporation or me in any
way or manner. (Please print or type all information requested. Additional paper
should be attached if needed.)
Name _____________________________________________________
First
Middle
Last
Address___________________________________________________________________
Street
City
State Zip
Driver's License No.__________________________
Social
Security No.___________________________
Residence Telephone ( )_____________________
Best
Time to Call: ________am _______pm
PERSONAL INFORMATION
Date of Birth______________ Marital Status______________
Spouse's Name______________ Spouse's Occupation______________
Spouse's Date of Birth______________
Spouse's
Social Security No.______________
Number of Dependents______________ Age of
Dependents______________
Last former residence__________________________________________________
I am a citizen of_________________
I
have permanent residence rights in____________________
My immigration Status, if applicable, is____________________________________
(Please attach copies of supporting data.)
Have you ever been convicted of a felony or misdemeanor or are such charges
pending, being appealed. or are you under indictment? (Do not include minor
traffic violations) YES NO
Have you ever been adjudicated bankrupt? YES NO
Are you or your employer providing products, goods or services to Quickly or any of its licensees? YES NO
If you answered "yes" to any of the above, please provide details on a
separate sheet.
BUSINESS EXPERIENCE - Present Employment
Company:____________________________________
Position:______________________________________
Address:______________________________
Employed
From: ______________to______________
Annual Salary:___________________________
Supervisor:__________________________________
Telephone:( )_____________________
Describe duties, responsibilities and number of employees supervised:
___________________________________________________________________________
___________________________________________________________________________
May we contact your present employer? YES NO
May we contact you at your business? YES NO
Please attach a resume of your previous experience.
EDUCATION
State your educational experience, including name and location of schools, years
completed and degrees earned.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
BUSINESS INTEREST
To what extent will you be actively involved in the day-to-day operations of the
restaurant?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What percent of the equity of this restaurant business will you
own?____________%
What amount of cash will you personally invest in this business?
$__________________________________
What is the source of these funds?
___________________________________________________________________________
___________________________________________________________________________
Will you have a business partner(s)? YES NO
If you have a business partner, who will be the Operating
Partner?___________________________
What is the total amount of cash your business partners will vest in this
business?
$_________________________
Will any partners interest in the franchise be encumbered in any way or subject
to an agreement between partners? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
Will any person or entity other than the partners be entitled to receive,
directly or indirectly, part of the profits from the operation of the
restaurant? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
Please list business partners:
Name
Estimated Net
Worth % Proposed Investment
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1)___________________ ____________________ ________ _____________________
2)___________________ ____________________ ________ _____________________
3)___________________ ____________________ ________ _____________________
4)___________________ ____________________ ________ _____________________
Do you currently have an interest in a fast food business or any other business
ventures? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
If you are approved for a Quickly Trademark License, will any partner be involved in any
non-Quickly business activity? (This includes all business activities, not just
restaurants) (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
Will the Operating Partner receive income from any source other than the
restaurant? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
What are your location preferences?
___________________________________________________________________________
___________________________________________________________________________
NOTE: Separate application and financial statements are required of each
partner/owner.
The undersigned certifies that the information furnished in this Quickly
Trademark Licensing Application is true, correct and complete. I also authorize Quickly
USA to make any additional credit/character checks which it deems necessary, and
to release to prospective financing sources such financial and other information
concerning me (us) in its files as may be requested.
Dated:_________________, 200___
Applicant Name:_________________________ Signature:_________________________________
Spouse Name:_________________________ Signature:_________________________________
PLEASE ENCLOSE A COPY OF A PROFESSIONALLY PREPARED FINANCIAL STATEMENT.
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