Confidential Qualification Information
This form will aid you in preparing and presenting personal information for the Confidential use of our Executive Committee. The submission of this information places no continuing obligation on either King Lombardi Acquisitions, Inc., franchisor of VR Business Brokers or you, the prospective franchise owner. The information provided will be held in strict confidence. We will not contact your employer or references without your prior approval.

PERSONAL DATA

Required

Required

Name:

Last

First

M.I.

Social Security Number

Address:

City:

State:

Zip: 

Telephone:

 Date of Birth: 

Home

Business

Best Time Time to Contact:
May we contact you at your business number?
Marital Status:

Spouse's Name:

Name & Ages Of Children:

How many persons, including yourself, are dependent on you for support? 
Does your spouse work?   

Type of work?

Spouse's Annual Earnings
Has any business in which you were an officer, director, or shareholder ever failed, filed bankruptcy, or become insolvent or compromised debts?

If yes, give details
 

EDUCATION
Highest grade completed: High School 1 23 4 College 1 2 3 4 Major
 

OCCUPATIONAL HISTORY: (List most recent experiences first)
Dates: From/To Name and Address of Business Position and Responsibilities, 
Reason for Leaving		 Annual Earnings
 
FINANCIAL DATA: (Include joint assets if shared by you)
APPLICANT ASSETS APPLICANT LIABILITIES
Cash (Checking & Savings) Notes Payable: Name Payee Below  $
Investments    To Banks
 Stocks, Bonds, CD's  Other
Accounts and Note Receivable  Installment Credit Card Debts
Real Estate Owned ( Market Value)  
 Home
 Other
Automobile(s): Year, Make   Automobile(s) Debt
Other Accounts Payable
Personal Property and Furniture Mortgage(s) Payable on Real Estate
Face Value Life Insurance   First Mortgage
Cash Surrender Value Life Insurance   Home Equity Line of Credit
Retirement Accounts   Unpaid Real Estate Taxes
  401-K Unpaid Income Tax
  IRA Secured Loans
Other Assets - Itemize Other Liabilities & Debts
Total Assets Total Liabilities

Net Worth (total Assets - Total Liabilities)
 
PERSONAL REFERENCES
Name Address and Phone Occupation
I certify that the information I have provided on this application is complete and correct. I hereby authorize King Lombardi Acquisitions, Inc. franchisor of VR Business Brokers or its authorized agent to obtain verification of any of the above information, and I authorize the release of such information to King Lombardi Acquisitions, Inc. franchisor of VR Business Brokers or its authorized agent.

Required

  
Email Address Date

Submit