PORT CITY JAVA® CAFÉS, COFFEEHOUSES & ROASTERY :: PROSPECTIVE FRANCHISEES INFORMATION

PORT CITY JAVA® CAFÉS, COFFEEHOUSES & ROASTERY

Prospective Franchisees Information

We are ready to put our full resources behind you to make your venture a success. Whether this represents another concept for your organization, or this is your first venture, we welcome you to explore the possibilities of successfully operating a Port City Java®.

Personal Data
Full Name:
DOB:
Address:
City:		State:	Province:	Zip Code:
Home Phone*:		Work Phone:
Fax:		Email*: (Must be correct)

Marital Status:	Single Married	Number of Children: Ages of children:

Educational Background ( please list schools attended, years attended and grade of degree attained):

Profession ( Current employer / years):

Dates	Company	Position	Nature of Business	Annual Income
				$
				$
Any other business in which you are an owner, partner or officer?
May we contact you at work? Yes, best time to call: No

Spouse's Profession ( Current employer / years):

Spouse's Employment History (Please list current employment first)
Dates	Company	Position	Nature of Business	Annual Income
				$
				$

Personal Background Information:
Are you a U.S. citizen? Yes No If not, citizen of what country?
Have you ever failed in a business or filed bankruptcy? Yes No If yes, please explain:
Are there any lawsuits pending against you? Yes No If yes, please explain:
Have you ever been convicted of a felony? Yes No If yes, please explain:
Have you ever owned a franchised business? Yes No If yes, what business and when?
Have you ever visited a Port City Java®? Yes No If yes, where?
Have you worked for Port City Java® or any of our franchisees? Yes No If yes, where?
How did you find out about the Port City Java® franchising program?
Do you or anyone that would be involved in the business have food service experience? Yes No If yes, please explain?
If No, are you willing to hire someone with food experience to help you operate the business? Yes No
What is your timeline for getting started?
Why would you like to be a Port City Java® franchisee?
Why do you think you would be a good Port City Java® franchisee?
Do you intend to operate your franchise personally? Yes, full-time Yes, part-time No
If not, who will be responsible for the daily operation of your Port City Java®? (Please list names and addresses)
Are you interested in a multiple development territory? Yes No Don't know
Do you or one of the participants intend to continue your current employment? (Multiple selections possible) self spouse partner(s)
In what city do you want to open a Port City Java® franchise?
1st choice:
2nd choice:
3rd choice:
Would this business be your sole source of income? Yes No
Amount of financing available for Investment: $

If you are going to form a Corporation, LLC or Partnership:
Name of Corporation:		Date Filed:	State:
Stockholders or Partners:
Name	Address	Phone	Occupation

References:
Personal:
Name	Title	Address		Phone



Credit:
Institution	Type of Acct.	Acct#	Contact	Phone

Other comments:

Assets
Net Worth	$ (Required item)
If you do not meet our financial requirements will you have investors or partners involved? Yes No
If No, please explain how you plan on funding this opportunity.
Liquid Assets:	$ (Required item)

* indicates required information

I understand that the granting of a franchise is at the sole discretion of the franchisor, Port City Java®

I understand that any information I receive from the Franchisor or from any employee, agent, or franchisee of the Franchisor is highly confidential, ("Confidential Information"), has been developed with a great deal of effort and expense to the Franchisor, is being made available to me solely because of the Questionnaire. I agree that I shall treat and maintain all Confidential Information as confidential, and I shall not, at anytime, without the express written consent of the board of directors of the Franchisor, disclose, publish, or divulge any confidential Information to any person, firm, corporation or other entity, or use any Confidential Information, directly or indirectly, for my own benefit of Franchisor.

I authorize the procurement of an investigative consumer report and understand that it may contain information about my background, character, general reputation, mode of living, credit worthiness and job performance. I understand that, upon written request within a reasonable period of time, I am entitled to additional information concerning the nature and scope of this report or investigation relating thereto.

This authorization for release of information includes but is not limited to matters of opinion relating to my character, ability, reputation and past performance. I authorize all persons, schools, companies, corporation, credit bureaus, and law enforcement agencies to release such information without restriction or qualification to a credit bureau or security consultant selected by the franchisor and Port City Java® in other parts of the world, to any of the above named parties and any of their officers, agents, employees and servants. I voluntarily waive all recourse and release them form liability for complying with this authorization. This authorization/release shall apply to this as well as any future request for an investigative consumer report by the above named firm. I agree that a photocopy, facsimile, printout, or other electronic copy of this release will be considered as valid as an original and my electronic submission of this form as valid as if I had affixed my written signature.

I have read this Questionnaire and everything I have stated in it is true. Additionally, I understand that the information provided by me will be relied upon by the franchisor.

Port City Java Cooperative Headquarters • 101 Portwatch Way • Wilmington, NC 28412 • 910.796.6646

The Port City Java® logo, “globally grown, artisan roasted™”, “a revolution is brewing®”, Fairganic®, and Slush’n Joe®, are all registered trademarks owned by PCJ Franchising, LLC.