Section 1 of 4

You have indicated an interest in purchasing a franchise for the development and operation of one or more Lady of America® Centers. The information requested from you in this document is for the exclusive use of Lady of America Franchise Corporation. in evaluating your qualifications for becoming a Lady of America Franchisee and undertaking the desired development and will otherwise be held in the strictest confidence. Unless we agree to waive that requirement, you must provide all of the information requested before your Application will be considered.
 

I. Personal Data

Your Name: Age: yrs
Spouse’s Name: Age: yrs
   
Home Address:
City:
State:
Zip:
How long: years      months
   
Home Phone:    - 
Best Time to Call:
 
Work Phone:    - 
Best Time to Call:
   
Fax Number:    - 
   
E-mail Address:
 
Children/Dependents:
   
Education: