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*Last Name:

*First Name:

Spouse's Name:

*Address:

*City:

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*Zip/Postal Code:

*Years at Address: Select Value... less than 5 5 to 10 10 to 15 15 to 20 more than 20 (How many years at present address)

Home Phone:

*Work Phone:

Fax Number:

Best Time to Call:AnytimeMorningAfternoonEvening

*Email:

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*Business Name:

*Address:

*City:

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*Zip/Postal Code:

*Position:

*From: *to (MM/YYYY)

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Zip/Postal Code:

Position:

From: to (MM/YYYY)

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Owned a Business?:Yes - No

If Yes, Type?:

*Assets:$

*Liabilities:$

*Net Worth:$

*Assets Available:$ (Unencumbered Liquid Assets Available)

*Equity in Residence:$ (List Equity in Personal Residence)

Other Real Estate:$ (List Equity in Other Real Estate)

*Full Time?:Yes - No — (Would you devote full time to this business venture?)

*Family Participation?:Yes - No — (Do you have other family members that would be active in the Franchise?)

If Yes, Describe:

*Any Partners?:Yes - No — (Would you have any business partners?)

 If Yes, please identify below.

Name:

Address:

City:

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Zip/Postal Code:

Phone:

Active in Business?:Yes - No

Name:

Address:

City:

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Zip/Postal Code:

Phone:

Active in Business?:Yes - No

Name:

Address:

City:

State: Select State... Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code:

Phone:

Active in Business?:Yes - No

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*Previous Franchise?:Yes - No — (Have you ever been involved in a franchise?)

If Yes, Explain:

*Why do you think you would like to sell Dippin' Dots?:
 

*What skills do you possess that would make you an outstanding Dippin' Dots Franchisee?:
 

*List geographical areas of interest for retailing Dippin' Dots:
 

*First Introduction?: (Where were you first introduced to Dippin' Dots?)

*# of Units Desired:Yr 1-2 Yr 3-4 Yr 5-6

*Desired Opening: (Desired Opening Date of First Shop — MM/DD/YYYY)

Specific Location Preference:

*First Choice:

*Second Choice:

Other than the Dippin' Dots website, where have you seen Dippin' Dots Franchise Ads or information (check all that apply)

 Trade Publication:

 Trade Show/Exhibition in:

 TV Show:

 Website (other than dippindots.com):

 Friend:

 Business Associate:

 Dippin' Dots representative: