Application First Name*Last Name*Phone*Email* Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweStreet Address*Address Line 2City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificProvine / Territory*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonState / Province / Territory*Zip / Postal Code*Are you a US Citizen?* Yes No Do you have access to the funds needed to open a Growth Coach franchise?* Yes No Are you a defendant in any lawsuits or legal action?* Yes No Are you a veteran?* Yes No Have you ever filed bankruptcy or are you in process of filing bankruptcy?* Yes No Have you ever been convicted of a felony or misdemeanor (other than traffic violations)?* Yes No Driver's License # or State ID #*Driver's License State*Date of Birth* Savings Account Balance*Home Value*Value of Stocks, Bonds, 401k or Investments*Value of Other Assets, Property or Investments*Total Value of Assets*Current Salary / or Fees*Dividends, Interest or Real Estate Income*Other Income*Total Income*Balance Due on Auto Loans*Balance Due on Mortgage*Balance Due on Other Loans or Debts*Total Liabilities*Your Estimated Net Worth (Total Assets plus Income minus total liabilities)*Do You Have a Spouse or Partner That Will Be Actively Involved in the Franchise?*YesNoWhat is Your Spouse or Partner's Name?Do You Plan on Financing Any Portion of Your Franchise?*YesNoWhat Method of Financing Are You Considering?Home Equity401k, Retirement FundSBA or Bank LoanRolloverFamily LoanOtherRate Your Overall Computer Skills, 5 being the highest*12345Rate Your Overall Networking and Sales Skills, 5 being the highest*12345Rate Your Organizational Skills, 5 being the highest*12345Signature*I, ____________ herby authorize The Growth Coach Franchise upon the execution of this consent form, to investigate the information contained in my application, and other background information, for the sole purpose of obtaining information relevant to my qualifications as independent franchisee thereof. I understand that this means I may be subject of a 'consumer report' from an outside agency, which report may contain information about my creditworthiness, credit standing, credit capacity, character, police and criminal records, general reputation, personal characteristics and mode of living, whichever are applicable. By signing below, I authorize The Growth Coach to obtain or cause to be obtained, a consumer report upon receipt of this form or at any time during which I am a franchisee.The Growth Coach is an equal opportunity company and does not discriminate against applicants with regard to race, color, gender, sexual orientation, age, religion, disability or any characteristic protected by applicable law.I understand that inquires on this application, which ask for my address and date of birth, are for identification purposes only. I understand that age is not considered in making decisions concerning independent franchisees.I release The Growth Coach or its agents and any person or entity that provides information pursuant to this form any and all liabilities arising from any claims, lawsuits,or other actions in regard to the information obtained from any and all of the above referenced sources.I further agree that the giving of any false, misleading or incomplete information will be grounds for denial or termination.I agree on my own behalf to indemnify, defend and hold harmless The Growth Coach, its parent, subsidiaries, affiliates, employees. agents and customers from and against any demands , claims, liability arising from the gathering and use of any information obtained from any and all of the above referenced sources.The above information is my true and complete legal name and all information is correct to the best of my knowledge. 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