Blenz Franchise Application Form 1Personal Information2Partner(s) Information3Education4Employment History5Financial Information6General Information7Professional Services8Personal Profile Date (MM/DD/YY)(Required) MM slash DD slash YYYY Last Name(Required)First Name(Required)SIN/Social Security No.Date of Birth (MM/DD/YY)(Required) MM slash DD slash YYYY Address(Required)City(Required)Province / State(Required)Postal / Zip Code(Required)Length at Present Address(Required)Ownership(Required) Rent Own E-mail Address(Required) Home Phone No.(Required)Mobile Phone No.(Required)Business Phone No.(Required)Marital Status(Required) Single Married Spouse’s Last Name(Required)Spouse’s First Name(Required)Number of Children(Required)Ages(Required)How many hours per week are you planning to devote to the business?(Required)Please enter a number from 1 to 150.Will your spouse be active in the business?(Required) Yes No If yes(Required) Full Time Part Time Spouse’s Occupation(Required) Will there be any other active partners in this business? Yes No If yes(Required) Full Time Part Time Partner 1 Name(Note: If you have a partner, please have them submit a separate application)Percentage of OwnershipPlease enter a number from 1 to 100.Partner 2 Name(Note: If you have a partner, please have them submit a separate application)Percentage of OwnershipPlease enter a number from 1 to 100.Partner 3 Name(Note: If you have a partner, please have them submit a separate application)Percentage of OwnershipPlease enter a number from 1 to 100.Partner 4 Name(Note: If you have a partner, please have them submit a separate application)Percentage of OwnershipPlease enter a number from 1 to 100. High SchoolHigh School Grade 9 10 11 12 13 CollegeCollege Grade 1 2 3 4 UniversityUniversity Grade 1 2 3 4 If any, what languages do you speak?List any courses related to retail sales or management: 1 Company NameType of BusinessCompany AddressPhone NoPositionSalarySupervisor NameEmployed From (MM/YY) MM slash DD slash YYYY Employed To (MM/YY) MM slash DD slash YYYY May we contact this employer? Yes No Describe your duties and responsibilitiesState your reason for leaving2 Company NameType of BusinessPositionSalarySupervisor NameEmployed From (MM/YY) MM slash DD slash YYYY Employed To (MM/YY) MM slash DD slash YYYY May we contact this employer? Yes No Describe your duties and responsibilitiesState your reason for leaving3 Company NameType of BusinessPositionSalarySupervisor NameEmployed From (MM/YY) MM slash DD slash YYYY Employed To (MM/YY) MM slash DD slash YYYY May we contact this employer? Yes No Describe your duties and responsibilitiesState your reason for leaving4 Company NameType of BusinessPositionSalarySupervisor NameEmployed From (MM/YY) MM slash DD slash YYYY Employed To (MM/YY) MM slash DD slash YYYY May we contact this employer? Yes No Describe your duties and responsibilitiesState your reason for leaving AssetsCashCash Assets 2Cash Assets 3Stocks & BondStocks & Bond assets 2Stocks & Bond assets 3AutomobilesAutomobiles assets 2Automobiles assets 3Real EstateResidenceOther ResidentialCommercialRecreationalOTHER ASSETSLIABILITIESNotes Payable - BanksNotes Payable - Banks 2Notes Payable - Banks 3Other Notes PayableOther Notes Payable 2Other Notes Payable 3Life Insurance LoansLife Insurance Loans 2Life Insurance Loans 3Auto LoansAuto Loans 2Auto Loans 3MortgagesMortgages 2Mortgages 3OTHER LIABILITIESTOTAL ASSETSNET WORTHTotal Assets Minus Total Liabilities - See Glossary for detailsSpouse’s IncomeOther Sources of IncomeAnticipated Source of Funds for this Venture?CREDIT REFERENCESCompanyAddressPhone No.Account No.Company 2Address 2Phone No. 2Account No. 2Company 3Address 3Phone No. 3Account No. 3By completing and submitting this application, the undersigned: Certifies the completeness and accuracy of the information submitted herein. The undersigned will ensure that all information provided in this application is accurate, current and complete, and will promptly update any information if it changes. BLENZ will rely upon the information provided by the undersigned in considering the undersigned’s suitability as a potential BLENZ franchisee and in entering into a franchise agreement with the undersigned (if applicable). Consents to BLENZ obtaining credit reports concerning the undersigned and such other information as may be deemed necessary by BLENZ in connection with this application. Consents to BLENZ’ collection, use and disclosure of the personal information provided in this application for BLENZ to evaluable the undersigned’s financial strength and suitability as a potential BLENZ franchisee. BLENZ will not disclose the undersigned’s personal information except as required and permitted by applicable law. Use of the undersigned’s personal information is subject to BLENZ’ Privacy Policy (a copy of which is available at www.BLENZ.com). Acknowledges that the undersigned’s submission of this application does not constitute an offer to purchase a franchise and does not obligate the undersigned in any way. How did you hear about BLENZ COFFEE?Please list desired areas for a location1st Choice2nd Choice3rd ChoiceAre you willing to relocate? Yes No If yes, where?(Required)Do you drink coffee? Yes No Have you ever been self-employed? Yes No If yes, what was the business?(Required)Has your company or any other you had ownership in ever declared bankruptcy or failed? Yes No If yes, state the reason, place and date of discharge:Have you ever been party to any civil litigation? Yes No If yes, state details:Have you ever been charged with a criminal offense? Yes No If yes, state details: LEGAL COUNSEL CONTACT Acting on your behalf for this transactionNamePhone No.AddressACCOUNTANT CONTACTNamePhone No.Address Please provide an overview of your past business experience, past professional sales experience, personal goals and why you are interested in a Blenz Coffee Franchise. Also, please outline your expectations of operating a Blenz Coffee Franchise.