Please complete this application, print it, sign it, and fax it to Tilden at (516) 746-1288
Application Date

1. Geographical Location Preferred
First choice
Second choice
Third choice
 
2. Personal
Name

Social Security No.

Spouse/co-applicant

Social Security No.

Home Address

City

State

Zip

Years at this address Best time to reach by phone
Home phone Work phone
Single Married
Number and ages of minor children and other dependents

 
Birthdate
Spouse/co-applicant birthdate
Education (Highest level completed at school)
 
Spouse/co-applicant
Are you party to any past or present legal action?
Yes No
Have you or spouse/co-applicant ever been convicted of a felony?
Yes No
Have you, spouse/co-applicant or business ever been involved in bankruptcy, insolvency or compromise with creditors?
Yes No
If you answered "yes" to any of the above, please explain:
3. Operational Plan
How many centers are you interested in?
Are you considering a partner(s)?
Yes No
Will you devote your full time to this business?
Yes No
  If no, indicate how you will divide your time:
 
Will members of your family be directly involved with the day-to-day operation of this business?
Yes No
  If yes, list who and in what capacity:
 
List any partners or associates who will join you in this venture. (They should complete a separate profile.)
 
4. Financial Statement
Assets   Amount in Even Dollars
Cash in Following Banks (itemize)    
 
 
 
Stocks and Bonds    
Marketable Securities    
 
Other Securities    
 
Notes Receivable    
Secured by Real Estate    
 
Secured by Other Collateral    
 
Unsecured    
 
Accounts Receivable    
 
Other    
 
Vehicles (Year and Make—Current Value)
 
 
 
Real Estate    
Primary Residence    
 
Other    
 
Other Assets    
 
 
 
 
 
 
Total Assets  
     
Liabilities   Amount in Even Dollars
Notes Payable to Banks (itemize)    
Secured    
 
 
Unsecured    
 
 
Other Notes Payable (Itemize)    
Secured    
 
 
Unsecured    
 
 
Taxes Payable    
Income Taxes    
 
Other Taxes    
 
Due on Vehicles
 
 
 
Debt on Real Estate    
Residence    
 
 
Other    
 
 
 
Other Liabilities (Itemize/Describe)    
 
 
 
Total Liabilities  
Net Worth  
Total Liabilities and Net Worth  

Analysis of Capital Available to Invest
  Amount Description
Cash Available
Other Liquid Assets
 
 
Partners
Real Estate Equity
 
Other
Total Capital
 
Additional Financing Sources Anticipated
 
 
 
Assets Available to Secure Additional Financing
 
 
 
 


Annual Sources of Income    
Salary, Bonus or Commissions    
 
Dividends    
 
Real Estate Income    
 
Other Income (describe)    
 
 
 
Total  
   
The information requested in this form is provided by the applicant(s) for the specific purpose of obtaining a TILDEN Franchise. As such, it is for internal use only, and will be kept in strict confidence.

The undersigned expressly agree(s) that all banks, institutions, persons, firms, and corporations referred to or referenced in the foregoing are authorized to give TILDEN any and all pertinent information they may request concerning this franchise application. By signing, I (we) affirm that all information provided in this application is true, accurate and a complete representation of my (our) financial qualifications and background.
   
Signature
Date Signed
   
Spouse/Co-Applicant Signature
Date Signed
Please complete this application, print it, sign it, and fax it to Tilden at (516) 746-1288.