International Confidential Questionnaire

Thank you for your interest in Homewatch CareGivers! If you prefer to fax the Confidential Questionnaire to us, please click here to download the form in PDF format.

Applicant Information:

First Name:* Last Name:*

Applicant is: IndividualGroupCorporationOther (explain)

If group or corporation, please state size of group/corporation and length of time in business:

Complete Mailing Address:*

Address:*

City:*

Province/State:*

Postal:*

Country:*

Home Address: (If different than mailing address)

Address:

City:

Province/State:

Postal:

Country:

Business Address: (if different than mailing address)

Address:

City:

Province/State:

Postal:

Country:

Email Address:*

Website:

Telephone Numbers (include area code):

Best time to call:

Home:

Business:*

Mobile:

Fax:

Birthplace:

Date of birth:

Martial Status:

Spouse's name:

Spouse's occupation:

Will your spouse be active in the franchise? If yes, to what extent?

Full timePart timeNot at all

# of Dependents:

Dependent's Names/Ages:

Level of education completed:

School name and address	Years attended	Year graduated	Degree received

Special Training

Have you ever lived, attended school, or visited the United States? Please explain:

How did you hear about Homewatch CareGivers? (please be specific):

Professional Experience

Are you currently employed?

YesNo

Length of current employment:

Present/most recent position: (Please list company name, type of business, position(s) held, dates position(s) held, and your most significant accomplishments.)

Previous position: (Please list company name, type of business, position(s) held, dates position(s) held, and your most significant accomplishments.)

Are you currently or have you ever been a master franchisee? (If yes, list franchise or franchises and relationships to each)

Do you currently own, or have you ever owned, your own business?

YesNo

If yes, please provide a few details:

Other business affiliations (officer, director, partner, etc.)

Please explain any business relationships you have ever had with any United States entities:

Future Business Plans

When would you like to open your Homewatch CareGivers business?

In what country or territory are you interested?

To what extent do you expect to be involved?

Do you plan to have a financial partner? YesNo

If yes, please identify all potential partners:

Partner Name:

Partner Address:

Partner Phone number:

Will your partner be active in the franchise? YesNo

Please state your professional capabilities, experience, and resources that you believe will enable you to successfully develop a franchise network in your country.

Financial Information

Please state the amounts of financial resources available to you to capitalize this opportunity. Please also indicate the source of this capital (for example: personal, corporate, financial partners, loans):

TOTAL ASSETS (include currency type):

TOTAL LIABILITIES (include currency type):

NET WORTH (include currency type):

Have you or your company ever been involved in a bankruptcy?

YesNo

If yes, please explain:

Have you ever been convicted of a felony?

YesNo

If yes, please explain:

Additional comments or information:

Please fax or email any relevant information about yourself or your company; for example: resumes, financial statements, etc.

The information on this questionnaire is true and correct to the best of my knowledge as of this date. I hereby authorize Homewatch CareGivers or its authorized agent to obtain verification of any of this information, and I authorize the release of such information to Homewatch CareGivers or its authorized representative. Homewatch CareGivers will not contact any present employers until express permission is granted. I understand this information will be held in strict confidence and that the delivery of this form does not cause either party to incur any obligations, except as stated in this paragraph.