Expression of Interest

Personal Information

First Name

Last Name

Date of Birth

Nationality

Gender

Relationship Status

Email Address

Mobile Phone

Drivers Licence Number

Address

Apartment/Suite/Flat Number

City

State

Post Code

Country

Business Information & Experience

Preferred Territory

Expected Timeframe to Start Your Business

Have you, or do you own any other businesses? (if so, please provide details)

Have you, or do you own another Franchise? (if so, please provide details)

Share your previous professional experience (input n/a if uploading cv/resume below)

Upload cv/resume

Chipmunks franchises are a demanding 7-day a week business - How do you expect to manage a store if you were to become a Franchisee?

Why are you attracted to the Chipmunks franchise?

Will you have a business partner? If yes, please provide details

Have you ever been refused Insurance? If yes, why?

Do you have any criminal convictions? If yes, please provide details:

Financial Position

Assets

Property value ($)

Vehicle value ($)

Shares value ($)

Cash value ($)

Superannuation value ($)

Other assets value ($)

Total assets value

Liabilities

Mortgage ($)

Investment loans ($)

Vehicle loans ($)

Personal loans ($)

Credit cards ($)

Tax debt ($)

Other liabilities ($)

Total liabilities

Net position

Source of Funding

Home ($)

Cash ($)

Loan ($)

Other ($)

General Disclosure

The information collected in this application will be used by Chipmunks Playland & Café to assess the suitability of potential franchisees and, in the case that this application is successful, for the purposes of preparing the relevant Franchise Agreement. This confidential information will not be provided to any other person, excluding advisers to the franchisor such as lawyers, accountants, and consultants, or used for any other purposes. You have the right to request copies of all information held by Chipmunks IP Ltd about you and to correct such information.

In addition to the above, a Confidentiality Agreement must be entered into by the parties before any confidential information is given to you.

You authorize us to contact any person listed in this application to verify the relevant information that you have provided and to seek further information reasonably required to assess your suitability as a franchisee.

All potential candidates for a new franchisee should undertake their own due diligence and seek independent ongoing financial and legal advice.

Declaration

I have answered the questions and provided information in this form to the best of my knowledge and as far as I am aware, the answers and information are true, complete and correct in all respects, and no relevant information has been omitted.

I acknowledge that if any information included in the application is false, misleading or deceptive in any material way, the Franchisor will have the right to terminate any Franchise Agreement entered into, and may have suffered loss as a result of relying on the information provided.

I understand that this application form does not constitute an agreement to grant or accept a franchise.

Signed

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