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Confidential qualification report.

Please fill out this form as completely as possible. All information supplied is for the exclusive use of DirectBuy and will be kept strictly confidential. You may also contact Debbie Bowen, Vice President of Franchise Development, at 800-454-0018 or send an email to franchising@directbuy.com .

If you simply would like a Franchise Information Packet, request information.
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Personal Information
   
*First Name
*Last Name
*Street Address 1
Street Address 2
*City
*State/Province
*Zip/Postal Code
*Country
*Telephone - Day ( )
*Telephone - Evening ( )
Fax ( )
*Email Address
*Age
*Social Security Number
Number of Children
*Do you Own or Rent?
   
*Are you currently a DirectBuy Member?
Which Center are you a member of?
   
*Marital Status
   
Spouse Information
   
*First Name
*Last Name
*Age
*Social Security Number
   
Employment Information
   
*Employment Status
*Position Held
*Business Name
*Street Address 1
Street Address 2
*City
*State/Province
*Zipcode
*Country
   
Financial Information (Balance Sheet)
  
Assets 
  
*Cash in checking account
*Cash in saving account
*Listed Stocks & Bonds
*T-Bills, Money Mkt. CD's etc.
*Real Estate (Present Value)*
Your Own Business (Net Value)
Money Due To You**
Other Assets***
Total Assets
* Describe Real Estate Properties:
** Explain Money Due to You:
*** Describe Your Other Assets:
  
Liabilities 
  
*Owing On Real Estate
*Owing On Real Estate - Other
Other Obligations  
Total Liabilities
  
*What is the amount of capital you have for this franchise?



If needed, note the items shown in the above statement which you plan to convert into cash to purchase a DirectBuy franchise:
If the required amount is not available, how would the investment be obtained?
*Have you ever filed for bankruptcy?  
When?
*Have you ever been a party to any criminal or civil lawsuits (other than minor traffic violations) in the past 5 years?  
Please Explain
  
*What net monthly income is necessary for personal living expenses for the first six months? (per month)
  
*If DirectBuy is not expanding in your area, would you be willing to relocate?
Explain?
Is there a particular geographical area that you would prefer?
1st Choice
2nd Choice
3rd Choice


Please Read And Indicate You Agree

I (We) understand that the above information is the first step in obtaining a better understanding of my (our) qualifications for a DirectBuy Franchise. Submission of this information does not obligate DirectBuy, Inc. in any manner to approve this application.

I (We) authorize DirectBuy, Inc. to contact any and all third parties listed in this application, including but not limited to banks or other lenders to confirm information in this application. I (We) also authorize DirectBuy, Inc. to contact credit services (such as Dunn and Bradstreet or Equifax), to determine my (our) financial position and to conduct such background investigations as DirectBuy, Inc. may consider appropriate in order to evaluate my (our) application.

I (We) understand that this application cannot be processed unless my (our) agreement is indicated below by clicking the appropriate button. I (We) hereby certify that the information contained in each of the items above is true and complete.