Prospective Broker Profile

In order for us to provide you with additional information and to further consider you for our program, please complete the questions listed below.

You may also choose to download the PDF form by Clicking Here and fax it to us at (323) 954-1051. Thank you.

PERSONAL INFORMATION

Your Name:*
Spouse:

Address:*
City:*
State:*
Zip Code:*
Home Phone:
Work Phone:
Cellular:*
Fax:
Email Address:*

Educational Background:*	HS Grad Some College University Degree
Can you supply character references, as required by our lenders? * Yes No

EMPLOYMENT INFORMATION

(Your employer will NOT be contacted)

FINANCIAL INFORMATION

Funds available for investment in this business (Cash, Credit Cards, etc.): *

Method of payment for the $13,800 investment: *

GENERAL INFORMATION

Do you have experience in this business? *	Yes No
Please explain:
Do you plan to have a partner?	Yes No
If so, will your partner be active?	Yes No

From what source did you learn about our business?
Please specify source: *
If approved, when would you attend certification? *

Submission Method

Signed:*

This is a confidential evaulation profile, not a contract and does not bind either party.

* = Required to Submit