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.