DENT DOCTOR FRANCHISE APPLICATION

NAMES

Will the business by owned/run in a corporate entity?

If so, please give name and registration number of entity (if available) and indicate member % shareholdings in 1.1

Member Name % shareholding

PERSONAL INFORMATION

(copy must be completed for each principal owner / shareholder)

2.7    Dependents:

BUSINESS EXPERIENCE

Present occupation

Describe your duties, number of employees supervised and your responsibilities:

Previous business experience (previous to current )

PERSONAL FINANCIAL STATEMENT

R  Salary / Wage   Bonus / Commission   Dividends & Interest   Property income (net)   Business profits   Other  income   TOTAL ANNUAL INCOME

How much are you in the position to invest for the following?

GOALS

UNDERTAKING

I hereby warrant to Dent Doctor that the information contained in this application represents my true and fair
financial and personal situation and is in all respects complete and not misleading.
I understand that Dent Doctor will rely on this information to decide whether or not to enter into a franchise agreement with me.
I further undertake to advise Dent Doctor of any material change to the information contained in this application.

I authorize Dent Doctor to seek and rely on information from references and financial institutions listed
in this application in order to verify the accuracy thereof.

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