Criterium Engineers Franchise Confidential Questionnaire

All information will be held strictly confidential.
If there will be more than one owner of the franchise, each must also complete a personal financial statement.
Your Net worth should exceed $100,000 for a franchise.

* The security of your data and information is very important to us. This form is transmitted to us through a secure, encrypted connection protected by a Secure Socket Layer (SSL) certificate. For additional security, Criterium’s network is monitored 24/7 by a third-party security team.

Phone: (800) 242-1969
Website: https://theengineeringfranchise.com
Email: franchising@criterium-engineers.com

"*" indicates required fields

Name*

First Last

Email*

I confirm that I have the financial resources to make an investment of between $65,000 and $125,000 at this time.

Will this franchise be your primary source of income?*

Yes

Are you planning to finance this franchise?*

Yes

What personal (net) income do you expect in:

Year 1*

Year 3*

Year 5*

Have you, your spouse, or your business ever been involved involved in bankruptcy, insolvancy, or compromise with creditors?*

Yes

If "Yes", Please explain

I will provide the below Net Worth, Sources of Income and Capital financial information at a later date.

ASSETS

1. Cash*

2. Accounts & Loan Receivable*

3. Life Insurance, Cash Value*

4. Stocks & Bonds*

5. Real Estate*

6. Automobiles, Other*

7. Other Assets*

TOTAL ASSETS*

LIABILITIES

1. Notes Payable to Bank*

2. Notes Payable to Others*

3. Accounts Payable*

4. Mortgage on Real estate*

5. Credit Card Debt*

6. Other Liabilities*

TOTAL LIABILITIES*

NET WORTH*

CURRENT SOURCES OF INCOME

Salary - Applicant*

Salary - Spouse

Bonus/Commissions - Applicant*

Bonus/Commissions - Spouse

Dividends - Applicant*

Dividends - Spouse

Other Income - Applicant*

Other Income - Spouse

TOTAL INCOME - APPLICANT*

TOTAL INCOME - SPOUSE

CAPITAL AVAILABLE TO INVEST

Cash Amount*

Source*

Real Estate Amount*

Source

Partner/Family Amount*

Source*

Other Capital Amount*

Source*

TOTAL AVAILABLE*

By signing below I affirm that all of the data contained herein is a true representation of my personal and financial condition. If necessary, Criterium Engineers may obtain a copy of my credit report or other information as necessary.

Name*

First Last

Date*