Franchise Form

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Many centers are independently owned and operated.

Preliminary Qualification Report


Sarah® Adult Day Care Centers, Inc. will rely on the following information to analyze your qualifications and to better assist you in your exploration of Sarah® Adult Day Services, Inc. Franchise Opportunity. This information will remain confidential. The submission ofthis information places no continuing obligation on either you or Sarah® Adult Day Services, Inc. Please call our toll free number at: 800-472-5544 if you have any questions.



* Indicates required response

Personal Information

*First Name:

*Last Name:

*Address 1:

* City:

* State:

* Postal Code:

* Phone:

Work Phone:

* Cell Phone:

* Best Time to Call:

* Email Address

* Citizenship

Married:
 Yes No

Spouses Name:

Children:

Ages:

* Have you ever been convicted of anything other than minor traffic violation?
 Yes No

* Have any judgements been entered against you or a business you controlled or did control?
 Yes No

Education

* Please check the highest grade completed.
 High School College Graduate School

Business Consideration

* Have you ever owned a business?

 Yes No

* Type of Business:

* When are you available for an interview at our Corporate Office?

Financial Data - Assets

Liquid (cash, unrestricted securities)

* Restricted securities (IRA, 401K 9 (s), ect)

* Do you rent or own?
 Rent Own

Home Value (and other Real Estate)

* Other assets (auto, business, receivables, ect)

* Total Assets

Financial Data - Liabilities

Mortgages (all debt on all real estate)

* Other Liabilities (auto loan, credit care, ect)

* Total Liabilities

Financial Data - Net Worth

* Total Assets Less Total Liabilities

* Have you ever declared personal or business bankruptcy?
 Yes No

Partner Information

* Will you have any business partners?

 Yes No

Partner(s) Name

What involvement will they have?
 Financial Operational

General Information

* How did you hear about SarahCare?
 Visited SarahCare Center Advertisement Web Search Referral

* Based on the answer you selected for How did you hear about SarahCare? Please enter the details in the space below (Ex: Which SarahCare Location, What Ad Agency, Web Search Engine or Who referred you?)

Comments

By checking this box below you certify that, the statements are true and accurate.
 I hereby certify that to the best of my knowledge,information, and belief, the above statements are true and accurate. Should I continue pursuing Sarah® Adult Day Services, Inc. Franchise, I shall provide additional and more complete information to Sarah® Adult Day Services, Inc., as requested. Receipt, completion or submittal of this Preliminary Franchise Application is not intended to be construed as an offer to franchise. Offered by prospectus only.


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