ALL NEVADA INSURANCE INC. Application for a Franchise PERSONAL INFORMATION Name * Home Phone Business Phone Residence May we contact you at your business phone? Yes No City E-Mail Address * Date of Birth State Zip Code Social security number Spouse's name Spouse's social security number Names and ages of children Have you ever been convicted of anything other than minor traffic violations? Has any judgment ever been entered against you or your company or your employer where you were one of the litigants? Are you involved in pending litigation? If yes, explain. Have you or your spouse ever declared personal bankruptcy? If yes, explain. Are you a US citizen, a permanent legal resident or do you otherwise have the legal right to remain in the US to operate a franchise? YES or NO Yes No Are you fluent in another language? YES or NO If YES, which language? EDUCATION Last year of school completed Name of college and/or postgraduate school Degree Describe any training in sales, management or retailing BUSINESS EXPERIENCE Present occupation Position Dates employed Company Address Describe duties, number of employees supervised and responsibilities Previous business experience (List most recent first.) Occupation Position Dates employed Company Address Reason Left Describe duties, number of employees supervised and responsibilities Occupation Position Dates employed Company Address Reason Left Describe duties, number of employees supervised and responsibilities Have you ever owned your own business or franchise? If so, explain. Have you ever had a business failure? If so, explain. PERSONAL FINANCIAL STATEMENT INCOME STATEMENT FOR 12 MONTH PERIOD ENDING Perticulars Amount Salary, wages, bonus, commissions Dividends, interest Other income - specify source, e.g., business profits (self-employed), trust, spouse, etc. Total Please provide details on the following asset verification schedules (schedule numbers in parentheses). Assets Amount Cash on hand and in banks Vested profit sharing Securities, Bonds/debentures (1) Notes, accounts and mortgages receivable (2) Real estate-current market value (6) Net value of business interests (7) Other-automobiles and other personal property, etc. (4) Total assets Liabilities Amount Loans/notes/accounts payable (3) Real estate mortgages (6) Other debts or obligations (5) Total liabilities Net Worth Total liabilities and net worth ASSET VERIFICATION SCHEDULES (1) Listed securities, bonds/debentures No. Shares Description Pledged (yes/no) Current mkt. value Total (2) Notes/accounts/mortgages receivable Debtor Relation to applicant Nature of debt Maturity date Original face value Monthly payment Present balance Total (3) Loans/notes/accounts/bills payable (excluding mortgages) Lender Relation to applicant Nature of debt Secured yes/no Maturity date Original face value Monthly payment Interest Rate Present balance Total (4) Other Assets (e.g., stock options, cash value of life insurance, automobiles and other personal property, etc.) Description Current fair market value Total (5) Other debts and liabilities (e.g., insurance loans, alimony, child support, leases, contracts, legal claims, judgments, chattel mortgages, taxes, comaker or guarantor, etc.) Obligee Description Amount Total (6) Real estate (e.g., insurance loans, alimony, child support, leases, contracts, legal claims, judgments, chattel mortgages, taxes, comaker or guarantor, etc.) Address and description of property (residential, rental, vacant) Date acquired Title in name(s) of Original Cost Original mortgage Amount Mo. payments (incl. taxes,assessments) Current market value Current mortgage balance Net Value Total (7) Business Interests Name and address of business Description Type (Partner, Corp, Sole) Name of All Owners Relation to Applicant Percent Equity Buy/Sell Agreement Yes/No Valuation Method Net Value your interest Total Does your spouse or another person have any interest in any of the above assets? If yes, please explain and list assets. Have any of the above assets been acquired by you as a gift? If yes, specify assets, from whom and when. MISCELLANEOUS INFORMATION List any hobbies, community activities, special interests or other pertinent information Are you related by blood or marriage to any officer of All Nevada Insurance Inc.?If Yes Name and Relationship Are you or your employer providing products, goods or services to All Nevada Insurance or franchisees of All Nevada Insurance? If yes, please attach detailed information. Will you devote your full time to this business? The flexibility to relocate may be required. To which general geographic area(s) would you be willing to relocate for a franchise opportunity (i.e., Northwest, Southwest, Midwest, Northeast, Southeast)? Have you ever worked in an All Nevada Insurance agency? If so, where and when? Have you ever applied for an All Nevada Insurance agency? If so, where and when? Personal references (other than employers or relatives) Name in full Address Occupation Years known Confidential This application does not obligate either party in any manner. I submit the following information as my complete and true personal and financial condition as of the date shown below. In accordance with the Privacy Act (5 U.S.C. 552a) and the Freedom of Information Act, I expressly authorize any past or present employer, any law enforcement agency, federal, state or local, or any person who has personal knowledge of my character, work experience or criminal records to release this information to All Nevada Insurance’s Inc. (“All Nevada Insurance’s”). I understand and acknowledge that, as a condition of being considered for the All Nevada Insurance’s franchisee training program, I must submit to a credit history check and criminal background check to be performed by a third party entity of All Nevada Insurance’s choice. I understand All Nevada Insurance may use those results of the credit history and criminal background check in determining whether I will be placed into the franchisee training program or remain in All Nevada Insurance’s franchisee training program. If requested by All Nevada Insurance, I agree to supply statements from my professional advisors (i.e., banker, broker, accountant or attorney) verifying the above assets, and I also agree to furnish copies of federal income tax returns as filed for the last five years. I understand that All Nevada Insurance is relying upon all the above information as a material factor in considering my application to become a All Nevada Insurance’s franchisee, and I therefore agree to promptly notify All Nevada Insurance of any material change in any of the above information or any subsequent information provided to All Nevada Insurance. In addition, I release all persons from liability as a result of true, accurate information. I also certify that neither I nor any of my funding sources is, or has ever been, a terrorist or suspected terrorist, or a person or entity described in Section 1 of U.S. Executive Order 13224, issued September 23, 2001, as such persons and entities are further described at the Internet website www.ustreas.gov/offices/enforcement/ofac. I agree to comply with and/or to assist All Nevada Insurance to the fullest extent possible in All Nevada Insurance’s efforts to comply with the above Executive Order. I accept the term and conditions.