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Request for Consideration
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Click Download PDF to Download the “Request For Consideration Form” (PDF File)
Please send me information.
Name
*
First
Last
Day Phone
*
Evening Phone
Cell Phone
Email
*
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you Rent or Own?
How long at this address?
Current Occupation
How long in this occupation?
Education
Date of Birth
Marital Status
Married
Single
Divorced
Seperated
If Married, will your spouse participate in the business?
Spouse/Partner Name
First
Last
Email
Current Occupation
Annual Income
How long in this occupation?
Business Experience/Employment History: Please list YOUR last three (3) occupations including years of Employment, Company/City, Position & Annual Income.
Is your objective to?
Supplement
Transition
Replace Your Current Income
Invest
Be Actively Involved
Specify the cities or areas and state you are interested in
Why are you interested in the Advertising/Marketing Industry?
How long have you been looking at Business Opportunities?
What other types of businesses are you considering?
How did you hear about Axxess?
What specifically about the Axxess Franchise Program appeals to you?
On a scale of 1-10, with 10 being the highest, how committed are you to owning your own business?
What is your timeline for starting your own business? (in months)
Why do you believe you can successfully operate and manage an Axxess Franchise Program?
Financial Disclosure
This information serves only to show your ability to make the necessary investment to successfully capitalize your business.
Assets
Cash in Checking Account
Cash in Savings Account
Real Estate (Home Value)
Other Real Estate
Cash Surrender in Life Insurance
401K Assets
IRA Assets
Other Assets
Total Assets
Liabilities
Notes Payable to Banks
Notes Payable to Finance Companies
Real Estate Mortgage Indebtedness
Credit Cards
Other Liabilities
Total Liabilities
NET WORTH
Net worth (total assets minus total liabilities)
What amount of money do you feel comfortable investing?
What is your liquid capital?
Have you ever filed for bankruptcy?
Yes
No
If you have filed for bankruptcy, please explain.
On a scale of 1-10, with 10 being the highest, how committed are you to moving forward with Axxess Franchising?
Disclosure Statement
I understand the information I am receiving from Axxess Ventures, LLC or from an Axxess employee, agent, franchise, licensee or any of their affiliates is considered highly confidential. This material, concept and business model has been developed with a great deal of effort and expense to Axxess and is being made available to me because of my request and will be kept in strict confidence. I will not divulge or use any data, customer or employee names, addresses, techniques, methods, advertising materials, forms or any other information of any kind used in connection with Axxess Ventures, LLC without their consent.
Signature
Print Name
Date
Thank You for Your Request
For assistance, please email aaron@axxessfranchise.com or call toll free at (855) 292-2580
