| First Name * |
* |
| M.I. |
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| Last Name * |
* |
| Social Security Number |
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Address |
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City |
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State * |
*
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| Zip Code |
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Home Phone |
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Business Phone |
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| Date of Birth |
dd/mm/yyyy
*
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| Best Time to Contact |
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| May we contact you at your business number? |
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| Marital Status |
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| Spouses's Name |
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Name & Age of Children |
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How many persons, including yourself, are dependent on you for support? |
*
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Does your spouse work? |
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Type of work |
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Spouse's Annual Earnings |
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Has any business in which you were an officer, director, or shareholder ever failed,
filed bankruptcy or become insolvent or compromised? |
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If yes, give details |
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Education -
Highest grade completed |
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High School |
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College |
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Major |
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Occupational History: (List most recent experiences first) |
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Occupation #1 |
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Dates: From/To |
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Name and Address of Business |
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Position and Responsibilities, Reason for Leaving |
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Annual Earnings |
*
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Occupation #2 |
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Dates: From/To |
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Name and Address of Business |
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Position and Responsibilities, Reason for Leaving |
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Annual Earnings |
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Occupation #3 |
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Dates: From/To |
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Name and Address of Business |
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Position and Responsibilities, Reason for Leaving |
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Annual Earnings |
*
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Financial Data: (Include joint assets if shared by you) |
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Applicant Assets |
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Cash (Checking & Savings) |
*
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Investments |
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Stocks, Bonds CD's |
*
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Accounts and Note Receivable |
*
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Real Estate Owned (Market Value) |
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Home |
*
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Other |
*
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Automobiles (s) |
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Year |
*
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Make |
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Value |
* |
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Automobiles (s) |
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Year |
*
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Make |
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Value |
* |
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Life Insurance, and Retirement Accounts |
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Personal Property and Furniture |
*
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Face Value Life Insurance |
*
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Cash Surrender Value |
*
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401 (k) |
*
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IRA |
*
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Other Assets - Itemize
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*
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Total Assets |
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Applicant Liabilities |
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Notes Payable: Name Payee Below |
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To Banks |
*
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Other |
*
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Installment Credit Card Debts 1 |
*
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Installment Credit Card Debts 2 |
*
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Installment Credit Card Debts 3 |
*
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Installment Credit Card Debts 4 |
*
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Automobile(s) Debt 1 |
*
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Automobile(s) Debt 2 |
*
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Other Accounts Payable |
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Mortgage(s) |
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First Mortgage |
*
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Home Equity Line of Credit |
*
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Unpaid Real Estate Taxes |
*
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Unpaid Income Tax |
*
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Secured Loans |
*
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Other Liablilities & Debts
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*
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Total Liabilities |
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Net Worth (Total Assets - Total Liabilities) |
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Personal References |
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Reference #1 |
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Name |
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Address |
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Phone Number |
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Occupation |
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Reference #2 |
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Name |
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Address |
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Phone Number |
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Occupation |
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Reference #3 |
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Name |
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Address |
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Phone Number |
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Occupation |
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I certify that the information I have provided on this application is complete and
correct. I hereby authorize King Lombardi Acquisitions, Inc. franchisor of VR Business
Brokers or its authorized agent to obtain verification of any of the above information,
and I authorize the release of such information to King Lombardi Acquisitions, Inc.
franchisor of VR Business Brokers or its authorized agent. |
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Email Address * |
* |
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Signature Date |
*
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