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Veronica's Franchise

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Personal details
Company name (If applicable)
Applicants name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long have you lived at this address?*
If less than 3 years, please supply previous address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Identification*
Drop files here or

Max. file size: 200 MB.
Please upload your ID
Email*
Personal Information
Health*
- Good
- Fair
- Poor
Marital Status*
Partners Name
First Last
Your age*
Partners Age
Number & Ages of Children
Will your partner be active in running the business?
- Yes
- No
Have you even been convicted of anything other than a minor traffic incident?*
- Yes
- No
Please give details*
List any hobbies, community activities, sports and special activities*
Education
Level of last year studies completed*
Name of last place of learning*
Personal qualifications
Describe any formal training
Personal skills
Please list below any further skills you believe would support your application

Business experience / Employment history
Present occupation*
Describe responsibilities, duties, etc.*
Previous employment/business experience
Last 5 years - most recent first.
Name of Employee*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of business*
Position held*
Date commenced*
MM slash DD slash YYYY
Date finished*
MM slash DD slash YYYY
Duties*
Achievements*
Reason for leaving*
Previous employment/business experience
Continued.
Name of Employee*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of business*
Position held*
Date commenced*
MM slash DD slash YYYY
Date finished*
MM slash DD slash YYYY
Duties*
Achievements*
Reason for leaving*

General Information
Will you devote your full time to the business?*
- Yes
- No
Please state how you propose to operate the business*
Are you considerating a partner(s)?*
- Yes
- No
If so, additional questionnaires must be completed by the partner(s).
Why are you seeking a business?*
What level of income do you initially want to achieve per week from your business?*
Have you ever been declared bankrupt?*
- Yes
- No
Is any legal action current or pending against you or any company associated with you?*
When did you start looking for a business?*
What else have you looked at?*

Present Income (per year)
Wages or salary ($)*
Bonus or commissions ($)*
Dividends*
Other income
Present Fixed Outgoings (per year)
Mortgage/Rent ($)*
Other Loan Payments (vehicule, etc.)
Other
Assets & Liabilities
As at:
MM slash DD slash YYYY
Assets
Cash in bank / term deposits*
Securities / shares / bonds
Real State
Business
Money owed to you
Motor vehicles / furniture, etc.
Upload your financial documents*
Drop files here or

Max. file size: 200 MB.
Bank Statements, Tax Returns, etc.
Liabilities
Bank overdraft
Mortgages
Hire Purchase
Trade creditors
Taxes
Personal loans & other liabilities
How do you intend to fund the purchase of your business?
Would you need to borrow to finance your business?
Any other financial information that may support this application?

In your words, explain why you would like to become a Veronica's Insurance Franchise owner and what it will mean to you?

References
Please provide contact details for 2 references from past employers or business associates who may be contacted for background references. We will not contact these references until you are happy for us to do so.
Name
First Last
Business*
Phone
Name
First Last
Business
Phone
It is understood that the purpose of this application is for information purposes only. It is in no way binding upon either Veronica's Insurance Franchise or the applicant. The undersigned certifies that the information provided is true and correct, and acknowledges that it will be relied upon by Veronica's Insurance Franchise in assessing the candidates suitability.
Date
MM slash DD slash YYYY
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Consent*
I sign this application and agree to the privacy policy.

1.800.639.0082

This website and the franchise sales information on this site do not constitute an offer to sell a franchise. This offer of franchise can only be made through the delivery of a Franchise Disclosure Document (FDD). Certain states require that we register the FDD in those states. The communications on this website are not directed by us to the residents of any of those states. Moreover, we will not offer or sell franchises in those states until we have registered the franchise (or obtained an applicable exemption from registration) and delivered the FDD to the prospective franchisee in compliance with applicable law.

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1.800.639.0082
info@veronicasfranchise.com

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Veronica’s Corporation Insurance Agency Lic. CA #6000845. Veronica’s Franchise LLC AL #3000767114, AZ #3000767654, AR #3000767175, CO #632266, CT #2666530, DC #3000767149, DE #3000767199, FL #L108973, GA #209931, ID #762410, IL #3000767201, IN #3516546, IA #1002360166, KS #842737101-000, LA #854353, MD #3000767202, MI #125761, MN # 40674057, MS #15037260, MT #3000767123, NC #1000685303, ND #3000767124, NE #3000767130, NV #3516546, NJ #3000767132, NM #3000770074, OK #3000767127, PA #932779, RI #3000767125, SD #10022113, SC #3000767145, TX #2486626, UT #761961, VT #3515867, VA #147520, WV #3000767274, WA #1046380, WI #3000767129, WY #424865.


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