Personal Information

*First Name:
*Last Name:
SSN:
*Age:
*Street Address:
*City:
*State:
*Zip Code:
*Home Phone:
Best Time to Call:
*E-mail:
*Market Preference:
*How did you hear of us?

Investment Data
Not sure? Enter zero. If a field which requires a dollar amount does not apply to you or you are otherwise unsure what to enter, please enter a "0" (zero).

*Have you ever been convicted of a felony?
*Have you ever been involved in a bankruptcy?
*Are there currently any civil judgments against you or your spouse?
*Are there currently any civil suits pending against you or your spouse?
*State the amount of money you are prepared to invest in a Batteries Plus Bulbs franchise:
*Source of investment funds:
If other, please list:

Monthly Expenses

*Home Expense:
*Living Expense:
*Auto Expense:
*Other Expense:
*Total Mo. Expenses:

Financial Information

Assets

*Cash on Hand:
*Savings, Funds/Certificates:
*Stocks, Bonds, Securities:
*Retirement Plans, IRA, 401k:
*Home Market Value:
Other Real Estate:
Money Due You:
Other:
Total Assets:

Liabilities

*Notes Payable
*Revolving A/C Balances:
*Credit Card Balances:
*Home Mortgage:
Other Real Estate Debt:
*Auto Loans:
Other Debt:
Total Liabilities:
Net Worth:

Agreement

The undersigned acknowledges and agrees:

1. Batteries Plus, LLC shall not incur any obligation or liability by receipt of the completed form and shall be entitled to decline to proceed with the application for a Batteries Plus Bulbs franchise without giving any reason for the decision.

2. No one other than an authorized officer of Batteries Plus, LLC has the authority to approve the undersigned for a Batteries Plus Bulbs Franchise Agreement.

3. Any material misrepresentation, whether intentional or unintentional, in information supplied by the applicant in this form shall be grounds upon which Batteries Plus, LLC may immediately terminate any agreements executed by the undersigned and Batteries Plus, LLC.

4. I will certify all information provided in this Application, including financial data, is correct. By signing this Application I hereby authorize investigation of all statements and the financial information disclosed. I authorize any person or company to provide Batteries Plus Bulbs or its representative, with information, including without limitation, concerning my employment, work habits, character and credit history as may be requested by Batteries Plus Bulbs.

 
*Signature:
*Date: