Confidential Information Request Form [rank_math_breadcrumb] Please answer all questions CIRF Step 1 of 3 - Personal Information 0% Confidential Information Request FormYour Name(Required) First Middle Last Your Email Address(Required) Enter Email Confirm Email Date of Birth(Required) MM slash DD slash YYYY Date of application(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands How long have you lived here?(Required) Your Phone(Required)Marital Status(Required)SingledMarriedWidowedDivorcedSeperatedRegistered PartnershipFull Name of Spouse Occupation of Spouse Applicant's Franchise PlansWill the franchise be owned and operated by you or a group?(Required) Please explain fully (it's okay if you don't know at this point; we can have discussion around this)(Required)Who else should be included in the email communication (i.e. Spous or NA)? Please provide name if other than spouse listed above and email address.(Required) How much liquid capital do you have available for this business?(Required) Describe fully(Required)What area would you like your studio?(Required) Would you consider any other areas?(Required) EducationHigh School(Required) Location of School(Required) Date of Graduation(Required) MM slash DD slash YYYY College/Post-Secondary(Required) Dates of Attendance (mm/dd/yy)(Required)From (mm/dd/yy) - To (mm/dd/yy) Major and Minor Fields(Required) Location of School(Required) Diploma or Degree(Required) Date of Graduation (mm/dd/yy)(Required) Business and Experience RecordHave you been in business for yourself?(Required) Name and Address of Employer(Required) Position, TItle & Duties(Required)Date of Employment(Required)From: (mm/dd/yy) - To: (mm/dd/yy) Reason for Separation(Required)Name and Address of Employer(Required) Position, TItle & Duties(Required)Date of Employment(Required)From: (mm/dd/yy) - To: (mm/dd/yy) Reason for Separation(Required)Consent(Required)“I submit the foregoing 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 the Franchisor. If requested by the Franchisor, 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 the Franchisor is relying upon all the above information as a material factor in considering my application to become a franchisee, and I therefore agree to promptly notify the Franchisor of any material change in any of the above information or any subsequent information provided to franchisor. In addition, I release all persons from liability as a result of true, accurate information. Further, Franchisor confidential information and trade secrets will not be disclosed by Applicants to any other person or business entity, and will not be used by Applicants in any manner outside the evaluation process, either during or after the evaluation process.” Signature(Required)Date(Required) MM slash DD slash YYYY
