Thank you for your interest in Elder-Well^® Franchise opportunity. The completion and submission of this form places no continuing obligation on either Elder-Well^®, or the applicant. It will provide confidential information we need to determine if you are qualified to start the process of becoming a Elder-Well^® Franchise. This application form is not intended as an offer to sell, or the solicitation of an offer to buy a franchise. We offer franchises solely by means of our Franchise Disclosure Document (FDD). Certain states and foreign countries have laws governing the offer and sale of franchises. If you are a resident of one of these states or foreign countries, we will not offer you a franchise unless and until we have complied with all applicable legal requirements in your jurisdiction. Please attach additional pages as necessary. False or misleading statements on this form are grounds for terminating the application process and/or grounds for terminating your franchise, should you be granted one. This is not an employment contract or franchise agreement.

Please fill out all fields below:

Personal Information

First Name *

Last Name *

Email Address*

Address 1 *

Address 2

City *

State/Province *

Zip *

Country *

Home Phone *

Best Time to Call

Birth Date*

Gender

Martial Status

Home OwnerShip

American citizen/Landed immigrant:

Social security

Assets & Liabilities

Cash in hand and in banks

Marketable securities

Accounts/Notes receivable

Retirement plans

Real estate

Personal property

Business holdings

Life Insurance (CSV)

Other assets

Liabilities

Mortgages

Accounts payable

Notes payable

Loans on life insurance

Credit cards (total balance)

Unpaid taxes

Other liabilities

Total assets

Total liabilities

Total net worth

Annual Sources of Income

Salary

Investment

Real estate income

Other income

Total income

Total Contingent Liabilities

Loan co-signature

Legal judgement

Income taxes

Other special debt

Total contingent liabilities

Specific Data

When would you be ready to invest in your franchise?

What skills/experience do you have that will help you succeed in this business?

Why do you think this franchise will enable you to reach your personal goals?

Who will be responsible for the daily operation of your business?

How much cash do you have available for investment?

Are you now, or have you ever been party to any lawsuit -either as defendant or plaintiff?

Have you ever been convicted of any offense (including misdemeanors for which you have been fined $200 or more)?

Have you ever been convicted of a felony?

If so, explain

Have you ever filed for bankruptcy?

Bankruptcy filed date

Bankruptcy discharged date

Please list 3 area/location preferences

Additional questions?

This application is intended to obtain certain pre-qualifying information to be considered for a franchise. Any offer to sell, and any solicitation of an offer to purchase a franchise is made only by means of the applicable Franchise Disclosure Document and only in states where such offers and solicitations are permitted by law. We reserve the express right to approve or disapprove this Franchise Application in our sole discretion and you shall not be deemed to have been granted a franchise (and there shall be no binding obligations on either party) unless and until both parties have executed a definitive Franchise Agreement.