Tom & Chee Franchise ApplicationFirst Name*Last Name*Home Phone*Business PhoneAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business Name of Applicant*Date of Birth* Date Format: MM slash DD slash YYYY Are you a US Citizen?*YesNoDrivers License # or State ID#*Drivers License State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDo you have the funds necessary to open a Tom & Chee Franchise?*YesNoAre you a defendant in any lawsuits or legal action?*YesNoAre you a Veteran?*YesNoHave you ever filed bankruptcy or are you in the process of filing bankruptcy?*YesNoHave you ever been convicted of a felony or misdemeanor (other than traffic violations)?*YesNoAssetsCash on Hand & in BanksSavings AccountsIRA or Other Retirement Account (Describe in Section 5)Accounts & Notes Receivable (Describe in Section 5)Life Insurance-Cash Surrender Value Only (Describe in Section 8)Stocks and BondsReal EstateAutomobiles (Describe in Section 5, and include Year/Make/Model)Other Personal Property (Describe in Section 5)Other Assets (Describe in Section 5)TotalLiabilitiesAccounts PayableNotes Payable to Banks and OthersInstallment Account (Auto)Installment Account (Auto) Mo. PaymentsInstallment Account (Other)Installment Account (Other) Mo. PaymentsLoan(s) Against Life InsuranceMortgages on Real EstateUnpaid Taxes (Describe in Section 6)Other Liabilities (Describe in Section 7)Total LiabilitiesNet WorthTotalSection 1: Source of IncomeSalaryNet Investment IncomeOther Income (Describe below)*Alimony or child support payments should not be disclosed in "Other Income" unless it is desired to have such payments counted toward total incomeReal Estate IncomeDescription of Other IncomeContingent LiabilitiesAs Endorser or Co-MakerLegal Claims & JudgementsProvision for Federal Income TaxOther Special DebtSection 5: Other Personal Property and Other Assets(Describe, and, if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and, if delinquent, describe delinquency.)Section 6: Unpaid Taxes(Describe in detail as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)Section 7: Other Liabilities(Describe in detail)Section 8: Life Insurance Held(Give face amount and cash surrender value of policies – name of insurance company and Beneficiaries.)Consent* I authorize the SBA/Lender/Surety Company to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness.By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with this form is true and complete to the best of my knowledge. I understand that SBA or its participating Lenders or Certified Development Companies or Surety Companies will rely on this information when making decisions regarding an application for a loan or a surety bond.*Print Name*Date* Date Format: MM slash DD slash YYYY