Preliminary Questionnaire

Instructions

• Please complete the entire form and submit for review. If you have any questions, please call: 800.554.3343.

Personal Information

• First Name (required)
  
• Middle Name
  
• Last Name *
  
• SalutationDr.Mr.Mrs.MissMs.
• Are you married?
  YesNo

If married, spouse's name:

• First Name
  
• Middle Name
  
• Last Name
  
• Birth Date
  
• Spouse's Birth Date
  
• Street Address
  
• City
  
• StateAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
• Zip Code
  
• Email
  
• Home Phone
  
• Mobile Phone
  
• Business Phone
  
• Do you have children?
  YesNo
• If so, age?
  
• Will you have partners in the business?
  YesNo
• If so, provide the name and email address for each partner.
  
  *Please note, each partner must complete a separate application.

Business Experience/Education

• If you are self-employed, please describe your business and/or industry.

• Your Employer
  
• Position
  
• Annual Income
  
• Spouse's Employer
  
• Position
  
• Annual Income
  
• Have you ever owned a business?
  YesNo
• Have you ever owned a childcare business?
  YesNo
• Level of EducationHigh SchoolCollegeGraduate School
• Major
  
• Degree
  
• Are you or your spouse currently serving in the Military, or are you a Veteran?
  YesNo
• Type of Discharge
  

General Information

• Have you ever filed for personal or business bankruptcy protection?
  YesNo
• If so, year of bankruptcy:
  
• Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?
  YesNo
• Are there any felony or misdemeanor charges pending against you?
  YesNo
• Are you a citizen of the United States?
  YesNo
• If no, do you hold permanent resident status in the United States?
  YesNo
• Are you a named party in any pending litigation?
  YesNo
• Have any judgements been entered against you or a business you control or did control?
  YesNo
• If so, year(s) of judgements:
  
• How did you first hear about Kiddie Academy?
  
• Have you ever visited a Kiddie Academy?
  YesNo
• If yes, where?
  
• What is your timeframe for opening a Kiddie Academy^® franchise?
  
• Have you visited Kiddie Academy's website?
  YesNo
• Who will have primary day-to-day responsibilities of operating your Kiddie Academy^® franchise?
  
• Do you plan on operating your Kiddie Academy on a full-time basis as your primary means of income?
  
• Do you have a preferred area to locate your Kiddie Academy^® franchise? (town, city, county)
  
• How did you hear about Kiddie Academy^®?
  Current Customer
  Direct Mail
  Event
  Online
  Print Ad

  Radio
  Referral
  Signage/Building
  TV

   

Financial Information

• As a crucial part of our review process, please enter your financial information in the categories below. This information will help determine if you meet our minimum requirements. Once your information is filled in, the Total Assets, Total Liabilities and Total Net Worth will be automatically calculated.
• *Although initially not required, at some point, Kiddie Academy will require bank statements and other documentation verifying the information contained below.
• Assets (A)
• Liabilities (B)
• Cash (checking and savings)
  
• Bank Loans
  
• Stocks & Bonds (excluding retirement)
  
• Mortgages (balances)
  
• Real Estate (residence)
  
• Notes Payable
  
• Real Estate (investment)
  
• Credit Card Debt
  
• 401(k)
  
• Margin Accounts
  
• IRA
  
• Other Liability (itemize)
  
• Other Assets (itemize)
  
• Other Liability (itemize)
  
• Other Asset (itemize)
  
• Other Liability (itemize)
  
• Other Asset (itemize)
  
• Other Liability (itemize)
  
• Total Assets (A)
  
• Total Liabilities (B)
  
• Total Net Worth = (A) MINUS (B)
  
• Unused Line of Credit (C)
  
• Funds Available for Investment (D) *
  

Real Estate Holdings

• Address
• Current Market Value
• Current Mortgage Balance
• Home Address
  
• Home Address Current Market Value
  
• Home Address Current Mortgage Balance
  
• Investment Property 1 Address
  
• Investment Property 1 Current Market Value
  
• Investment Property 1 Current Mortgage Balance
  
• Investment Property 2 Address
  
• Investment Property 2 Current Market Value
  
• Investment Property 2 Current Mortgage Balance
  
• Investment Property 3 Address
  
• Investment Property 3 Current Market Value
  
• Investment Property 3 Current Mortgage Balance
  

I/we understand that the information provided above will be material to the determination by Kiddie Academy Domestic Franchising, LLC (“Kiddie Academy”) whether I/we meet the eligibility requirements of the Kiddie Academy® franchise opportunity. I/we agree to promptly notify Kiddie Academy of any material changes to the information provided. I/we hereby certify that the information presented above is true and accurate, and understand that my/our application could be denied if any of the information provided is false or misleading. The submission of the information or acceptance of my/our application places no continuing obligation on Kiddie Academy.

I/we hereby release Kiddie Academy and its members, officers, directors and employees from any and all liabilities, claims and/or causes of action regarding the use or disclosure of the information presented above.

• Applicant Signature *
  
• Date *
  
• Co-Applicant Signature
  
• Date