Franchise Application Form

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*


    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



    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



    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?