EDIT PDF Request for Consideration Form | Confidential Name: * First Name Last Name Date of Birth: Social Security, Passport or Country ID Number: Citizenship: Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What specifically drove you to contact Brooklyn Dumpling Shop at this time? (Please be specific: magazine, online ad, social media, tradeshow etc.) Area(s) of Interest: Number of Unit You Wish to Develop: How soon do you anticipate opening your first unit? 3 – 6 months 6-12 months 12 months + Highest level of education completed: Are you currently, or were you previously a franchise owner? YES NO BUSINESS EXPERIENCE Company Name: Type of Business: Address Address 1 Address 2 City State/Province Zip/Postal Code Country Present / Most Recent Position: Dates Position Held: Number of People You Directly Manage: Previous Positions Have You Ever Owned a Business? YES NO If Yes, What Type of Business? Do You Plan to Devote Full Time to This Business Venture? YES NO Will You Have Equity Partners? (If yes, please identify all partners in the Business Structure section of this form.) YES NO Why do you believe you can successfully operate a Brooklyn Dumpling Shop franchise in your area(s) of interest? Additional information you would like to share with us in evaluating your Request for Consideration form: Are you now, or have you in the previous ten years, been a party to any lawsuit, arbitration, mediation, bankruptcy or other legal proceeding? Yes NO If yes, please provide details: Have you ever been convicted of a felony? * YES NO If yes, please provide details: PERSONAL FINANCIAL STATEMENT Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Social Insurance Number or other Country ID Number: Assets: Cash - checking accounts $ Cash - savings accounts $ Certificates of deposit $ Securities - stocks / bonds / mutual funds $ Notes & contracts receivable $ Automobiles $ Vested interest in deferred compensation/profit sharing plans $ Real estate (market value) $ Other assets (specify) $ Other assets (specify) $ Total Assets $ Liabilities: Current Debt (Credit cards, Accounts) $ Notes payable (describe below) $ Taxes payable $ Real estate mortgages (describe) $ Other liabilities (specify) $ Other liabilities (specify) $ Total Liabilities: $ PROPOSED COMPNAY STRUCTURE Proposed Owner (1) First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Active in Franchise? YES NO Proposed Owner (2) First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Active in Franchise? YES NO Proposed Owner (3) First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Active in Franchise Yes NO Proposed Principal Operator First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country What will be your company's organizational structure? ( Partnership, Corporation, LLC etc?) If lender financing, please name specific resources: Thank you for your request for information! We appreciate your interest and will get back to you promptly with the details you need. If you have any more questions in the meantime, feel free to reach out.Brooklyn Dumpling Shop Canada
