The Xercize Studio, LLC
800.IMX.1336
CONFIDENTIAL FINANCIAL PROFILE

click here for a printable version of this form to fax
(Form must be FAXED to 212.997.7356, signature required)

PERSONAL INFORMATION:

Date:


Social Security Number:

Date of Birth:

Male: Female:

Full Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Fax:

Email Address:

Residence:
Own: Rent:

Number of Children:

Number of Dependents:

Single:  Divorced:  Separated:   Widowed:   Married:

Spouses Name:

How did you hear about the IM=X Pilates Studio?

Personal References: (Name Relationship & Years Known Telephone No. w/Area Code)

BUSINESS BACKGROUND:

Business References: (Name Relationship & Years Known Telephone No. w/Area Code)


PRESENT EMPLOYER:

SELF
Present Employer:

SPOUSE/PARTNER
Present Employer

SELF
Job Title:

SPOUSE/PARTNER
Job Title:

SELF
Job Description:

SPOUSE/PARNTER
Job Description:

SELF
Length of Employment:

SPOUSE/PARNTER
Length of Employment:

SELF
Annual Salary:

SPOUSE/PARTNER
Annual Salary:

SELF
Other Previous Postions of Significance:

PARTNER
Other Previous Postions of Significance:

 

SELF
Other Sources of Income:

PARTNER
Other Sources of Income:

QUESTIONNAIRE:

1. What is your preferred geographic market area(s)?
  First Choice:
  Second Choice:
  Third Choice:
   
2. Why do you want to become an IM=X Pilates Studio owner?
 
   
3. Please tell us why you believe you will be a successful business owner. Make specific reference to desirable character traits, your transferable skills, your work experience, and your professional goals.
 
   
4. Are you interested a single location or multiple locations?
  Single: Multiple:
  If Multiple Locations, how many?
  What is your time frame for expansion?
   
5. Are you a fitness professional?
  Yes: No:
  If yes, please describe your fitness background:
   
6. Will you manage your facility or will you hire a manager?
  Manage your own facility: Hire a Manager:
   
7. Have you ever owned a franchise before?
  Yes: No:
  If so, please describe:
   
8. Have you ever owned your own business before?
  Yes: No:
  If so, please describe:
   
9. Have you ever been convicted of a felony?
  Yes: No:

Complete the following or send personal and/or business financial statements:

ASSETS
LIABILITIES
Cash on Hand & In Banks
 Notes Payable to Banks
Stocks, Bonds, Securities
 Notes Payable to Individuals
Retirement Funds
 Total Credit Card Debt|
Loans Owed to You
 Vehicle Loans
Primary Residence
 Home Mortgage
Other Real Estate
 Other Mortgage
Businesses Owned
Student Loans
Any Other Assets
 Any Other Debts
Total Assets
 Total Liiabilities

Total Net Worth:    
Assets Liabilities Net Worth
- =

Estimated Credit Rating:

Excellent: Fair: Poor:

Credit Score if Known:

The person(s) signing this application below certify that the above information is true and correct to the best of their knowledge. The undersigned authorize The Xercize Studio, LLC to make inquiries it considers necessary and appropriate concerning the above information and to give information about this transaction to other parties, including credit-reporting agencies, in accordance with the law. The undersigned agree to notify The Xercize Studio, LLC of any material changes in the above stated financial condition.


Entering your name in the boxes below will serve as your signature
Date: Signature:
Date: Signature: