First Name:
Last Name:
Address:
City:
State:
Select a state...
Outside US
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VQ
VT
WA
WI
WV
WY
Zip:
Country:
What is the best phone number to contact you (primary phone)?
What is the best time to contact you?
Alternate Phone Number:
E-mail:
Would you like to receive periodic eMails regarding The Grout Doctor?
Yes
No
Will you have partners besides you & your spouse?
Yes
No
If so, please explain who will be partnering with you?
How did you hear about The Grout Doctor franchise opportunity?
Select one...
Internet
Referral
Newspaper
Magazine/Guide
Vehicle Advertising
Customer Advertising
If other, please explain:
Please tell us about your background:
Describe your business and/or professional background:
Have you ever owned a business?
Yes
No
If yes, please explain:
Have you ever owned a franchise?
Yes
No
If yes, please explain:
Are you currently employed?
Yes
No
If so, what is your current occupation?
If currently employed, do you plan on keeping your current employment if you were to own a Grout Doctor franchise?
Yes
No
Have you ever declared bankruptcy?
Yes
No
If yes, please explain:
Have you ever been convicted of a felony?
Yes
No
If yes, please explain:
Are you currently involved in any lawsuits or other legal actions?
Yes
No
If yes, please explain:
Do you have any medical conditions or potential health issues, including any knee or back problems,
that may prevent, or limit you, from performing any services offered by The Grout Doctor?
Yes
No
If so, please explain:
Please provide the following financial information:
Total Cash available to invest:
Select an option...
$5-$10,000
$10,000-$20,000
$20,000-$30,000
$30,000-$50,000
$50,000-$75,000
$75,000-$100,000
$100,000+
Other capital available to invest including stocks, bonds, mutual funds, non-retirement accounts:
Select an option...
$5-$10,000
$10,000-$20,000
$20,000-$30,000
$30,000-$50,000
$50,000-$75,000
$75,000-$100,000
$100,000+
Are you planning on financing all or part of the franchise fee?
Yes
No
Have you made contact with a lender yet?
Yes
No
How much of your own money are you looking to invest in this franchise?
Select an option...
$5-$10,000
$10,000-$20,000
$20,000-$30,000
$30,000-$50,000
$50,000-$75,000
$75,000-$100,000
$100,000+
Is the capital available now to invest?
Yes
No
If no, when will it be available?
Please provide the following additional information:
What state are you interested in owning a Grout Doctor franchise?
Select a State...
Outside US
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VQ
VT
WA
WI
WV
WY
Please list cities and/or counties you are interested in:
If you are outside the US, please list the country you are interested in:
What is your time frame to open?
Select an option...
1-3 months
3-6 months
6-9 months
over 1 year
Are you interested in a multi-unit development agreement?
Yes
No
Do you plan to be an owner-operator?
Yes
No
If no, please explain:
Do you currently have a vehicle that you would consider using for this business?
Yes
No
If yes, please list the year, make, model and color:
Are you exploring other franchises?
Yes
No
If yes, which ones?
Any additional information that you would want us to consider?
As of today, based on what you know about The Grout Doctor please rate your overall interest in owning a Grout Doctor franchise?
