The Senior's Choice™
Qualifying Questionnaire
This questionnaire is an important factor in eventually becoming a member of The Senior's Choice™ network of business owners. Your answers and effort will be given our careful evaluation.

*Please Note: Although this form does not require all fields to be completed for submission, it is helpful to include as much information as possible for the evaluation process to be complete and thorough. A red asterisk ( * ), however, does denote required information be completed for the form to be processed.

Thank you.



Part I. Personal Information

* First Name: *
* Last Name: *
Address:
City:
State:
Zip Code:
* Home Phone:
* Area Code: * Number:
Business Phone: Area Code: Number:
  Mobile/Other Phone: Area Code: Number:
  * E-mail: *
1.
Do you own your home? Please enter Yes or No:
2.
Years at current address:
3.
Spouses Name:
4.
Spouses Occupation:
5.
Number of dependents living at home:
6.
 Last year of school completed:
7.
 College/University:
8.
 Degree:
9.
 Give a brief description of your current employment:
10.
 Describe some of your best qualities:
11.
 Are you currently using your strengths? Please enter Yes or No:
12.
If so, how?
13.
In summing up your accomplishments to date, which one gives you the most pride?
14.
What is your definition of success?
15.
 What will you most like about owning your own business?


Previous Experience (last 5 years):
1) Company:
City and State:
Type of Business:
Position:
Dates:
----From: Month: Year:
--------To: Month: Year:
2) Company:
City and State:
Type of Business:
Position:
Dates:
----From: Month: Year:
--------To: Month: Year:
3) Company:
City and State:
Type of Business:
Position:
Dates:
----From: Month: Year:
--------To: Month: Year:
4) Company:
City and State:
Type of Business:
Position:
Dates:
----From: Month: Year:
--------To: Month: Year:
5) Company:
City and State:
Type of Business:
Position:
Dates:
----From: Month: Year:
--------To: Month: Year:
6) Use the form field below if additional space is necessary for your experience:


Part II. Business Information

16.
 Have you ever filed bankruptcy? Please enter Yes or No:
17.
 If yes, when? Month: Year:
18.
 Have you ever been involved in a lawsuit? Please enter Yes or No:
19.
If yes, explain?
20. Do you have the financial resources to build and operate this business? (A minimum of $20,000, inclusive of the Membership Fee, will be required.):
21. Please state the total amount of your liquid assets available to start your business - i.e., cash accounts (checking, savings, CD's money market funds):

22. When would you like to start your business?
Month: Year:



Part III. References

1) Name:
Address:
Relationship: Years Known:
Phone Number:

2) Name:
Address:
Relationship: Years Known:
Phone Number:
3) Name:
Address:
Relationship: Years Known:
Phone Number:
4) Name:
Address:
Relationship: Years Known:
Phone Number:
5) Name:
Address:
Relationship: Years Known:
Phone Number:
6) Use the form field below if addtional space is necessary for your references:



Please review all the information you have entered and make sure all fields have been completed and entered accurately before proceeding.

When finalized, click the 'Submit Form' button below.
Thank you for your interest in The Senior's Choice™.



Clicking the 'Clear Form' Button will erase all information inputed.

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