Franchise Application Detailed Personal Application Personal DetailsFirst Name* Last Name* Email* Cell Phone*Birth date* MM slash DD slash YYYY Home OwnershipHome OwnershipRentOwnDriver License Number US Citizen?* Yes No Do you have an appropriate work visa? Yes No Spouse/PartnerSpouse/Partner Name: Spouse Birth Date MM slash DD slash YYYY Spouse Email Address Spouse Primary Phone Current AddressCurrent Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How many years at this address? Current EmployerEmployer Name Number of Years At Employer Title Work Address Background DetailsHave you ever been convicted or plead guilty or no consent to a felony?* Yes No Have you declared bankruptcy in the last 7 years?* Yes No Year Filed* Are you currently party to any legal action* Yes No Do you consent to a Background & Credit Check? (in the future, prior to a franchise being awarded)* Yes No FinancialsAnnual Sources of IncomeSalaryReal Estate IncomeInvestmentOtherAssetsBasic financial asset informationCash in CheckingCash in SavingsMarketable SecuritiesAccounts / Notes ReceivableRetirement AccountsPersonal PropertyBusiness HoldingsLife InsuranceOther AssetsAdditional Comments or Other AssetsLiabilitiesBasic liability informationMortagagesAccounts PayableNotes PayableLoans On Life InsuranceCredit Cards Total BalanceUnpaid TaxesOther LiabilitiesAdditional Comments or other LiabilitiesTotal Assets*Total Liabilities*Total Net Worth*Background and Credit Check Consent I understand that as part of the franchise purchase process, Image One Facility Solutions, Inc. (Image One) will make investigative inquiries on my background. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for purposes of purchase a Consumer Report may be made which may include information about your credit standing and capacity, character, reputation, personal traits, mode of living and other pertinent qualities for franchise ownership purposes including reasons for termination of past employment. Upon written request, information as to the nature and scope of the report will be provided (if one is made) if franchise award has been denied due to information obtained therein. I hereby authorize Image One to conduct background investigations including but not limited to a National Cross Reference of all 50 states showing actual past residences, obtaining a consumer credit report and any other information regarding my driving history and records, criminal history, and credit standing. This release is executed with full knowledge and understanding that the information is for the official use of Image One. A photocopy of this authorization can be accepted with the same authority as the original. If a franchise is awarded, this authorization shall remain on file and shall serve as ongoing authorization for Image One to procure consumer reports at any time during the term of my franchise agreement. I Give My Consent I agree to receive SMS messages & emailsCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ ADDRESS 3601 Algonquin Rd. Suite 100 Rolling Meadows, IL 60008 CALL US 630-616-1010
