Franchise Questionnaire

This franchise questionnaire for United Portraits will help you in preparing and presenting your personal information for confidential use by United Portraits to determine your qualifications as a franchisee. Please complete it with as much detail as possible. The completion of this form places no continuing obligation on either party. Please have each person signing fill out a separate application.

First Name

Last Name

Phone

Email Address

Home Street Address

Apartment / Building #

City

State

Zip Code / Postal Code

Country

Are You A U.S. Citizen? Are You A U.S. Citizen? Yes No

Are you a veteran? Are you a veteran? Yes No

Do you have access to the funds needed to open a United Portraits Franchise? Do you have access to the funds needed to open a United Portraits Franchise? Yes No

Are you a defendant in any lawsuits or legal action? Are you a defendant in any lawsuits or legal action? Yes No

Have you ever been convicted of a felony or misdemeanor (other than traffic violations)? Have you ever been convicted of a felony or misdemeanor (other than traffic violations)? Yes No

Have you ever committed any offenses against children? Have you ever committed any offenses against children? Yes No

Have you ever filed bankruptcy or are you in the process of filing bankruptcy? Have you ever filed bankruptcy or are you in the process of filing bankruptcy? Yes No

Driver's License # or State ID #

What state was this ID issued in?

Date of Birth

Savings Account Balance

Home Value

Value of Stocks, Bonds, 401k or Investments

Value of Other Assets, Property, or Investments

Current Yearly Salary

Dividends, Interest, or Real Estate Income (Yearly)

Other Income (Yearly)

Balance Due on Auto Loans

Balance Due on Mortgage

Balance Due on Other Loans or Debts

Your Estimated Net Worth (Total Assets Minus Liabilities)

Do you have a Spouse or Partner that will be actively involved in the franchise? Do you have a Spouse or Partner that will be actively involved in the franchise? Yes No

What is your Spouse or Partner's Name?

Do you plan on financing any portion of your franchise? Do you plan on financing any portion of your franchise? Yes No

What method of financing are you considering?

Rate your overall COMPUTER SKILLS, 5 being the highest Rate your overall COMPUTER SKILLS, 5 being the highest 1 2 3 4 5

Rate your overall SALES AND NETWORKING SKILLS, 5 being the highest Rate your overall SALES AND NETWORKING SKILLS, 5 being the highest 1 2 3 4 5

Rate your overall ORGANIZATIONAL SKILLS, 5 being the highest Rate your overall ORGANIZATIONAL SKILLS, 5 being the highest 1 2 3 4 5

SIGNATURE (TYPE YOUR FULL NAME)

15 + 12 =

By submitting this application I hereby authorize United Portraits Franchise upon the execution of this consent form, to investigate the information contained in my application, and other background information, for the sole purpose of obtaining information relevant to my qualifications as independent franchisee thereof. I understand that this means I may be subject of a ‘consumer report’ from an outside agency, which report may contain information about my creditworthiness, credit standing, credit capacity, character, police and criminal records, general reputation, personal characteristics and mode of living, whichever are applicable. By signing above, I authorize United Portraits to obtain or cause to be obtained, a consumer report upon receipt of this form or at any time during which I am a franchisee.

United Portraits is an equal opportunity company and does not discriminate against applicants with regard to race, color, gender, sexual orientation, age, religion, disability or any characteristic protected by applicable law.

I understand that inquires on this application, which ask for my address and date of birth, are for identification purposes only. I understand that age is not considered in making decisions concerning independent franchisees.

I release United Portraits or its agents and any person or entity that provides information pursuant to this form any and all liabilities arising from any claims, lawsuits, or other actions in regard to the information obtained from any and all of the above-referenced sources.

I further agree that the giving of any false, misleading or incomplete information will be grounds for denial or termination.

I agree on my own behalf to indemnify, defend and hold harmless United Portraits, its parent, subsidiaries, affiliates, employees. agents and customers from and against any demands, claims, liability arising from the gathering and use of any information obtained from any and all of the above-referenced sources.

The above information is my true and complete legal name and all information is correct to the best of my knowledge.