*First Name

*Last Name

*Street Address

*City

*State

*Zip Code

*Email

*Residential Phone

*Business Phone

Business Experience

*Present Occupation

*Name of Employer

From

To

Brief description of duties and responsibilites:

Prior Occupation

Name of Employer

From

To

Brief description of duties and responsibilites:

Education

Degree

Major & Minor

*High school

*College

Graduate School

Other (specify)

Financial Information

Please enter the amount of cash available for investment in a franchise.
$

What is your approximate personal Net Worth (value of all assets less all liabilities)?
$

Will you have any business partners?     Yes               No

Objectives

*Do you have a market preference? (city, region, etc.)

*Do you have an industry specialty? (bio-technology, food service, etc.)

*How did you hear about the Shock PR franchise opportunity?

What do you expect to achieve with a Shock PR franchise?

How much time do you expect to devote to this business?

*When would you be ready to start your new business?

Please add any relevant comments or experience that would help us to know you better:

Once we review your responses we will contact you. Thank you for considering Shock PR.