Please complete all the required fields before you submit the form." end if %>

This Franchise Application form, when completed, is an essential part of evaluating your qualifications to be awarded a Brightscape franchise. Print a copy for your records before pressing the Submit button. Before becoming a franchisee you will be required to submit additional information. This application allows us to start the process immediately.

Please answer all questions completely. Incomplete applications will not be considered. All answers will be held in confidence. The completion of this form does not obligate Brightscape or you in any way.

If you have questions completing this application form, please contact our Franchise Sales representative.

Personal Data

(*) Indicates Required Fields
*First Name:
Middle Name:
*Last Name:
*Street Address:
*City:
*State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zip Code:
*Home Phone:
Business Phone:
Cell Phone:
*Email Address:
*Gender:	M F
*Date of Birth:
*Social Security Number:	- -
*Driver's License Number:
*US Citizen:	Yes No
*Have you ever owned or been a partner in a business?	Yes No
Spouse Name:
Date of Birth:
Social Security Number:	- -
*Why are you interested in a Brightscape® franchise?
Please indicate the areas/locations where you are interested in operating a Brightscape's® franchise:
*First location preference:
Second location preference:
Third location preference:
*Are you willing to relocate:	Yes No
*What is your available capital for investment?
*What is your net worth?
*Have you ever had a bankruptcy or had a judgment against you?	Yes No
*Are you party to any claim or suits?	Yes No
*Are you currently under investigation or pending charge?	Yes No
*Have you ever been convicted of a crime?	Yes No
*Have you ever been sanctioned or had your licenses suspended or revoked?	Yes No

Previous Addresses for last 10 years

*Street Address:
*City:
*State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zip:
*List years at this address:

Educational History

*Name of College/Grad School:
*City:
*State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Major/Degree:
*Year Graduated:

Business Experience

Please give present or last position first
*In your employment verification check, may we contact your current employer?	Yes No
*Name of Company:
*Phone:
*Street Address:
*City:
*State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zip:
*Position:
*Salary:
*Name of Immediate Supervisor:
*Dates Employed:	from to

Management Goals

*Do you plan to personally operate the business, devoting full-time to this business?	Yes No
*Do you plan to have equity partners?	Yes No

Please carefully read our "Terms and Conditions" before submitting your application.

TERMS AND CONDITIONS

By submitting this application I certify that all information is true and complete.

I authorize Brightscape Investment Centers, Inc. and its agents to prepare or review a personal credit report and other information about me. These reports may include information as to my character, general reputation, personal characteristics, credit and mode of living. This information will be gathered through one or more of the following: employment and education verifications, personal references, personal interviews, my personal credit history based on reports from any credit bureau, my driving history, a social security verification, present and former addresses, criminal and civil history, and any other available record. I authorize all parties contacted on behalf of Brightscape Investment Centers, Inc. to release this information.

By submitting this application I acknowledge and accept the conditions stated above.

Before submitting this application please print a copy for your records.