Your Full Name (required)
Home Address (required)
City (required)
State (required)
Zip (required)
Phone (required)
Years at Current Address (required)
Email (required)
Occupation (required)
Married (required) YesNo
Spouses Name
Spouse Occupation
No. of Dependents
How did you hear about us?
Do you plan to devote full time to this venture? (required) YesNo
Are you willing to relocate? (required) YesNo
Do you plan to have equity partners? (required) YesNo
Geographic area of interest (please describe):
Briefly describe why you want to become a franchisee? (please describe):
Have you ever been convicted of a misdemeanor? (required) YesNo
If yes, please explain
Have you ever been convicted of a felony? (required) YesNo
Cash in Bank
Mortgages Due Me
Notes Due Me
Stocks and Bonds
Cash Value of Life Insurance
Real Estate Owned
Other Assets
Other
Total Assets
Notes Payable to Banks
Loans Against Cash Value of Life Insurance
Notes Payable to Others
Other Accounts Payable
Real Estate Mortgage Payable
Other Taxes Due
Other Liabilities
Total Liabilities
Total Liabilities and Net Worth
Annual Income (required)
Have you ever been involved as a debtor in proceedings under the U.S. Bankruptcy Code? YesNo
If so, please explain:
By clicking the send button below, I submit the above information as my complete and true personal and financial condition as of the date shown below. In accordance with the Privacy Act (5 U.S.C. 552 a), Freedom of Information Act and The Fair Credit Reporting Act, I expressly authorize any past or present employer, any law enforcement agency, federal, state or local, or any person who has personal knowledge of my character, work experience or criminal records to release this information to Hokulia Franchising, Inc. (“Franchisor”). I understand and acknowledge that, as a condition of being considered for a Hokulia Franchise, I must submit to a credit history check to be performed by a credit reporting agency of Hokulia Franchising. Inc. choice and authorizes and requests any consumer reporting agency to provide such information to Hokulia Franchising, Inc. I understand that the credit reporting agency will make the results of the credit history check available to Hokulia Franchising, Inc. and that Hokulia Franchising, Inc. may use those results as a factor in determining whether I will be granted a Hokulia franchise. If requested by Hokulia Franchising, Inc. , I agree to supply statements from my professional advisors (i.e., banker, broker, accountant or attorney) verifying the above assets, and I also agree to furnish copies of Federal Income Tax Returns as filed for the last five years. I understand that Hokulia Franchising, Inc. is relying upon all the above information as a material factor in considering my application to become a Hokulia franchisee, and I therefore agree to promptly notify Hokulia Franchising, Inc. of any material change in any of the above information or any subsequent information provided to Hokulia Franchising, Inc. . In addition, I release all persons from liability as a result of reporting true, accurate information. I also certify that neither I nor any of my funding sources, is or has ever been a terrorist or suspected terrorist, or a person or entity described in Section 1 of U.S. Executive Order 13224, issued September 23, 2001, as such persons and entities are further described at the Internet website www.ustrease.gov/offices/enforcement/ofac. I agree to comply with and/or to assist Hokulia Franchising, Inc. to the fullest extent possible in Hokulia Franchising, Inc.’s efforts to comply with the above law
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