ChiroWay Franchise Application

Franchise Application Form

Thank you for your time and interest. Please use this application to communicate why you would be a positive addition to ChiroWay’s family of Chiropractors.

Any information detailed on this form will be treated in a strictly confidential manner. ChiroWay Franchise, LLC utilizes the information provided on this form for the sole purpose of evaluating prospective franchisees, and will not sell or provide this information to any other party without written consent of the applicant. Please note that although every possible precaution is taken to protect the confidentiality of the application form, ChiroWay Franchise, LLC and its affiliates and their employees cannot be held responsible in the event that the information contained in this application is obtained by a third party.

ChiroWay Franchise, LLC

650 Commerce Drive, Ste 155

Woodbury, MN 55125

franchise@chiroway.com
877.442.4476

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you own or rent?*
How long have you lived at the address above?*
Phone*
Email*
Date & Place of Birth*
Spouse or Partner's Name*
Spouse or Partner's Occupation*
Marital Status*
Number of Children & Ages*
Other Dependents*
Business Experience*
Please Upload Your Resume or CV.
Accepted file types: pdf, jpg, doc, Max. file size: 146 MB.
How did you hear about ChiroWay Franchise and why are you interested?*
Have you ever been self employed?*
If yes, please explain.
Have you ever been involved in any litigation or arbitration with respect to your previous business history?*
If yes, please explain.
Will you work in the business full time?*
How many hours per week would you devote to your practice?*
Will you have investors?*
If yes, please provide name of each partner.
If married, will your spouse be involved in the business?*
If yes, how much involvement?
Location Preferences*
Please specify 3 geographic areas you are interested in by order of preference.
When will you be able to open a ChiroWay Franchise?*
Are you willing to relocate?*
Education
High School Name & Location*
College or University Name & Location*
Degrees Obtained*
Where did you attend Chiropractic School?*
Year of Graduation*
Additional Education or Certifications
Financial
All information provided is strictly confidential and will be treated as such.
Personal Financial Information as of (Date):*
MM slash DD slash YYYY
Personal Annual Income Salary ($):*
Dividends*
Real Estate Income*
Other Income*
Total Income*
Assets*
Please use the space below to disclose the amounts of the following 7 categories ($): Cash; Stocks/Bonds/Securities; Real Estate; Automobiles; Business Assets; Other Assets; Total Assets
Liabilities*
Please use the space below to disclose the amounts of the following 7 categories ($): Notes Payable; Bank Loans; Accts/Bills Due; Credit Card Balance; Unpaid Income Tax; Other Liabilities; Total Liabilities
Net Worth (Assets - Liabilities)*
How will you finance your practice?*
Specify cash amount and loan amount.
What is the source of this Capital?*
How much liquid cash do you have available for investment?*
Have you ever declared bankruptcy?*
If yes, explain.
Additional Information
Where did you first hear about ChiroWay?*
What do you like about our concept?*
Have you visited one of our locations?*
If yes, where?
How would you describe ChiroWay?*
What does "Franchising" mean to you?*
In your opinion, how would you describe the roles of the Franchisor and Franchisee?*
What are your goals and objectives for the next 5 years?*
Do you think the success or failure of the business is primarily your responsibility?*
Please comment on your response to the question above.*
Have you discussed this opportunity with any of our existing locations, franchisees or employees?*
If yes, which location(s)?
Additional Information or Comments
Professional References
Reference #1: Name*
First Last
Employer & Position*
Address*
Phone*
Reference #2: Name*
First Last
Employer & Position*
Address*
Phone*
Personal References
Reference #1: Name*
First Last
Employer & Position*
Address*
Phone*
Reference #2: Name*
First Last
Employer & Position*
Address*
Phone*
Bank and Credit Reference
Company*
Name of Contact*
Address*
Phone*
Signature
THE UNDERSIGNED APPLICANT (“APPLICANT”) CERTIFIES THAT THE INFORMATION IN THIS APPLICATION IS TRUE AND ACCURATE, AND UNDERSTANDS THAT THE INFORMATION PROVIDED WILL BE RELIED UPON BY CHIROWAY FRANCHISE, LLC. Applicant agrees to promptly notify ChiroWay Franchise, LLC of any material changes to the information provided. Applicant understands that the granting of a franchise is at the sole discretion of ChiroWay Franchise, LLC and that acceptance of this application is not a granting of a franchise. Franchises are granted only by execution of a written Franchise Agreement. Applicant understands that any information received from ChiroWay Franchise, LLC or from any employee, agent, or franchisee of ChiroWay Franchise, LLC, is highly confidential (“Confidential Information”), has been developed with a great deal of effort and expense to ChiroWay Franchise, LLC and is being made available to Applicant solely because of this application. Applicant agrees to treat and maintain all Confidential Information as confidential, and shall not, at any time, without the express written consent of ChiroWay Franchise, LLC disclose, publish, or divulge any Confidential Information to any person, firm, corporation or entity, or use any Confidential Information, directly, for Applicant’s own benefit or the benefit of any person, firm, corporation or other entity, other than for the benefit of ChiroWay Franchise, LLC. Applicant authorizes the release of any information deemed necessary by ChiroWay Franchise, LLC to verify any and all of the information contained in this application. This authorization for release of information includes but is not limited to matters of opinion relating to Applicant’s background, mode of living, credit worthiness, character, ability, reputation and past performance. Applicant authorizes all persons, schools, companies, corporation, credit bureaus, and law enforcement agencies to release such information without restriction of qualification to investigatory parties selected by ChiroWay Franchise, LLC, any of its officers, agents, employees and servants. Applicant voluntarily waives all recourse and releases them from liability for complying with this authorization. This authorization and release shall apply to this as well as any future information request. Applicant authorizes that a photocopy or facsimile of this authorization and release be considered as valid as the original.
Name*
First Last
Signature*
Date*
MM slash DD slash YYYY

Franchise Application Form

ChiroWay Franchise, LLC

Education

Financial

Additional Information

Professional References

Personal References

Bank and Credit Reference

Signature