ALL NEVADA INSURANCE INC.


Application for a Franchise


PERSONAL INFORMATION

EDUCATION

BUSINESS EXPERIENCE

Previous business experience (List most recent first.)



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

MISCELLANEOUS INFORMATION

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.