Advanced Information Request

Thank you for your interest in joining the Melt family.

  • Corporate office
  • 31556 Loma Linda Street, Temecula, California, 92592
  • Phone: 310-601-7907
  • Fax: 310-601-7906
  • Email: clivebarwin@meltgelato.com

* Denotes required field

*Email:
*Last Name:
*First Name:
Middle Name:
Date of Application:
Birth Date:
Age:
Telephone Number:
Current Address:
City:
State:
Zip:
How long have you lived there?
Previous Address:
City:
State:
Zip:
How long have you lived there?
Marital Status:
Full Name of Spouse:
Occupation of Spouse:
Names and Ages of Dependent Children
APPLICANT'S FRANCHISE PLANS
Will the franchise be owned and operated by you or a group? Please explain fully:
Amount of capital available for this business? Describe fully:
Territory for which application made:
Would you consider any other area?
What area(s)?
EDUCATION
PLEASE LIST ALL EDUCATION YOU HAVE RECEIVED INCLUDING HIGH SCHOOL, COLLEGE, MILITARY OR SPECIAL TRAINING.
Name of School:
Dates of Attendance:
Major & Minor Fields:
Location of School:
Grade Average or Class Standing:
Diploma or Degree:
Date of Graduation:
Name of School:
Dates of Attendance (From: (MM/DD/YY) - To: (MM/DD/YY)):
Major & Minor Fields:
Location of School:
Grade Average or Class Standing:
Diploma or Degree:
Date of Graduation (From: (MM/DD/YY) - To: (MM/DD/YY)):
BUSINESS & EXPERIENCE RECORD
GIVE A COMPLETE RECORD OF YOUR EXPERIENCE, BEGINNING WITH YOUR PRESENT OR LAST POSITION. INCLUDE MILITARY SERVICE.
Have you been in business for yourself?
Name & Address Of Employer:
Position, Title & Duties:
Dates Of Employment (From: (MM/DD/YY) - To: (MM/DD/YY)):
Supervisor’s Name & Title:
Reason for Separation:
Beginning salary ($):
Ending salary ($):
PHYSICAL CONDITION
General Physical Condition:
Date of Last Physical Exam:
List Any Physical Impairments Or Chronic Illnesses Which May Preclude Certain Types Of Activities:
INCOME
YEAR:
EARNED (salary, commissions, fees, etc.):
INTEREST & DIVIDENDS RECEIVED:
RENTS RECEIVED:
OTHER INCOME:
OTHER INCOME:
GROSS INCOME:
REFERENCES
PLEASE LIST THREE PROFESSIONAL & CHARACTER REFERENCES (Name Address Telephone):
PLEASE LIST THREE PROFESSIONAL & CHARACTER REFERENCES (Name Address Telephone):
PLEASE LIST THREE CREDIT REFERENCES (Name Address Telephone):
BANK REFERENCES (Name Address Telephone):
CONTINGENCIES
Do You Have Any Contingent Liabilities?
Yes No If So, Please Itemize
Are Any of Your Assets Pledged? Please Describe:
Are You a Defendant in Any Suits or Legal Actions?
Yes No Please Describe
Have you ever declared bankruptcy?
Yes No
CONFIDENTIAL FINANCIAL STATEMENT

ASSETS
Please enter whole values without a comma, round them off where needed.
Cash on Hand & Unrestricted in Banks:
U.S. Government Securities:
Notes Payable to Banks, Secured Direct Borrowings Only:
Notes Receivable, Discounted With Banks, Finance Companies, etc:
Life Insurance, Cash Surrender Value (Do not deduct loans):
Other Stocks & Bonds:
Real Estate:
Automobiles Registered in Own Name:
Other Assets (itemize):
TOTAL ASSETS
LIABILITIES & NET WORTH

Please enter whole values without a comma, round them off where needed.

Notes Payable to Banks, Unsecured Direct Borrowings Only:
Accounts & Loans Receivable:
Notes Receivable, Discounted with Banks, Finance Companies, etc:
Notes Payable to Others, Unsecured:
Notes Payable to Others, Secured:
Loans Against Life Insurance:
Accounts Payable:
Interest Payable:
Taxes & Assessments Payable:
Mortgages Payable on Real Estate:
Other Liabilities (itemize):

TOTAL LIABILITIES

 
NET WORTH (Assets - Liabilities):
“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 Franchisor. If requested by 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 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 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 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.”

THIS IS NOT A CONTRACT AND SUPPLYING OR COMPLETING THIS FORM INCURS NO OBLIGATION ON EITHER PARTY.