potential franchisee questionnaire

Personal Information

* First Name:	* Last Name:	Date:
* Address 1:	Address 2:
* City:	* State:	* Zip Code:
* Cell Phone:	Home Phone:	Work Phone:
Contact at Work: Yes No	* Email:	Marital Status: Single Married Divorced Widowed
Spouse First Name:	Spouse Last Name:
If you are considering a partnership for this franchise, please complete the following information about your prospective partner:
First Name:	Last Name:
Address 1:	Address 2:
City:	State:	Zip Code:
Cell Phone:	Home Phone:	Work Phone:
Contact at Work: Yes No	Email:	Marital Status: Single Married Divorced Widowed
Spouse First Name:	Spouse Last Name:

Current Employment

Company Name:	Title:	Start Date:
Address 1:	Address 2:
City:	State:	Zip Code:

Fitness Industry Experience

Club Operations

* Do you plan on working full time at your Anytime Fitness club?: Yes No

* If working with a partner, do they plan on working full time at the club?: Yes No

Location / Demographics (First Choice)

* Proposed City:	* State:	* Population:
* Nearby Cities:

Location / Demographics (Second Choice)

Proposed City:	State:	Population:
Nearby Cities:

Assets & Liabilities

Assets	Current Value
Cash on Hand (checking/savings)	($)
401K/IRA/Profit Sharing Plan	($)
Notes/Accounts Receivable (Schd. 5)	($)
Marketable Securities (Schd. 2)	($)
Life Insurance (Cash value only - Schd. 4)	($)
Homestead Owned (Schd. 1)	($)
Other Real Estate (Schd. 1)	($)
Automobile(s)	($)
Equity Value in Existing Business (Schd. 3)	($)
Other Personal Property	($)
Other Assets (specify separately)	($)
Total Assets	($)

Liabilities	Balance Owed
Mortgage on Homestead (Schd. 1)	($)
Home Equity or Line of Credit	($)
Auto Loans	($)
Credit Cards (balance of all)	($)
Other Loans (property/personal)	($)
Accounts Payable (Schd. 6)	($)
All Other Liabilities	($)
Alimony/Child Support (Balance)	($)
Taxes Owed	($)
Total Liabilities	($)
Net Worth (assets minus liabilities)	($)
Total Liabilities and Net Worth	($)

Income	Applicant	co-Applicant
Salary/Wages (C)	($)	($)
Commission/Bonuses	($)	($)
Rental Income	($)	($)
Investment Income	($)	($)
Business Income	($)	($)
Other Income	($)	($)
Other Income	($)	($)
Total Income	($)	($)

Monthly Liabilities	Applicant	co-Applicant
Mortgage or Rent (homestead)	($)	($)
Mortgage (Other real Estate)	($)	($)
Insurance/Property Taxes	($)	($)
Auto Loan/Lease Payment	($)	($)
Credit Card Payments	($)	($)
Alimony/Child Support	($)	($)
Liens/Judgments	($)	($)
Other Debt	($)	($)
Total Liabilities	($)	($)

Real Estate Owned | Schedule 1

Type of Property	Address of Property	Purch. Date	Original Cost	Current Mkt Value	Mortgage Balance	Monthly Payment

Marketable Securities | Schedule 2

Name of Security	Number of Shares	Purchase Cost	Date Purchased	Current Market Value

Equity in Existing Business(es) | Schedule 3

Name of Business	Ownership %	Date Ownership Acquired	Equity Value of Ownership

Life Insurance | Schedule 4

Insurance Company	Face Value	Cash Surrender Value	Beneficiary

Notes/Accounts Receivable | Schedule 5

Debtor	Description of Receivables	Repayment Terms	Balance Due
		Per
		Per
		Per

Notes/Accounts Payable | Schedule 6

Payee	Description of Liability	Repayment Terms	Unpaid Balance
		Per
		Per
		Per

Other

1. Have you ever filed for bankruptcy? Yes No If yes, please explain:

2. Are you currently or have you been the defendant in any suits or legal actions? Yes No If yes, please explain:

3. Has a tax lien ever been filed against you, your personal property, a business in which you have held ownership, or any business property in which you have held ownership? Yes No If yes, please explain:

I authorize Anytime Fitness, LLC. and its Assigns to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated dates. These statements are made for the purpose of either obtaining commercial credit or guaranteeing commercial credit. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001). Anytime Fitness, LLC may share your personal financial statement with its affiliates, if necessary.