Franchise Evaluation Form

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FRANCHISEE EVALUATION FORM

The purpose of this Form is for you to provide us general information to help evaluate your qualifications for MR
KATSU Franchise. This is not an application. If you qualify and a mutual interest develops, we will request
additional information at that time. This form should be completed by EACH proposed partner. Please print or type your
answers. You may attach additional pages if necessary to provide complete answers. Please answer all questions.
Personal Data
DATE OF APPLICATION: 20____ REF/CODE
Last Name First Name Middle Name

Tel. No. Fax No. Email Address:

Birthdate Age T.I.N.


SSS Number
Current Home Address/Zip Code Years of Residence

Previous Address Years of Residence

Company Name Position

Company Address:

Civil Status: (Check One) Height Weight


 Single  Married 
Widowed
Full Name of Spouse Occupation of Spouse

Names of Dependent Children Ages

Applicant’s Franchise Plan

I am interested in your franchise because:

Will the franchise be owned and operated by yourself or a group? (Check below)
I plan to be a franchisee: I plan to operate the franchise:
 actively involved in the business  as an individual
 passive and behind the scenes  with partners
Please explain fully.

Amount of capital available for this business.


Describe fully

Area/Location/Territory for which application made

Would you consider any other area?  YES  NO


What area(s)?

THIS IS NOT A CONTRACT AND SUPPLYING OR COMPLETING THIS FORM INCURS NO OBLIGATION ON EITHER PARTY.
Business Experience
Have you been in business for yourself?

Name and Address of Employer

Position/Title/Duties

Dates of Employment (from / / to / / ) Person Reporting Directly To/Title

Reason for Separation Starting Salary Ending Salary

Name and Address of Employer

Position/Title/Duties

Dates of Employment (from / / to / / ) Person Reporting Directly To/Title

Reason for Separation Starting Salary Ending Salary

Name and Address of Employer

Position/Title/Duties

Dates of Employment (from / / to / / ) Person Reporting Directly To/Title

Reason for Separation Starting Salary Ending Salary

Education
Name of School Dates of Attendance Course Attended/Graduated

Name of School Dates of Attendance Course Attended/Graduated

Name of School Dates of Attendance Course Attended/Graduated

Name of School Dates of Attendance Course Attended/Graduated

Physical Condition
General Physical Condition Date of Last Physical Exam

Attending Physician

List Any Physical Impairments or Chronic Illnesses


Which May Preclude Certain Types of Activities

Please explain.

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

Year ____________

Earned (salary, commissions, fees, etc.) Php______________

Interests & Dividends Received Php______________

Rents Received Php______________

Other Income
_____________________________________ Php______________

_____________________________________ Php______________

_____________________________________ Php______________

_____________________________________ Php______________

Gross Income Php______________

References

Please list three professional and character references (Name-Address-Phone No.-Fax No. )
1.
2.
3.
Please list three Credit References (Name-Address-Phone No.-Fax No)
1.
2.
3.
Bank References (Name-Address-Checking Account/Savings Account/Others)
1.
2.
3.

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