Personal
1.	Name:	*
2.	Home Address:	*
3.	City:	*
4.	State:	*
5.	Zip:	*
6.	Email:	*
7.	Home Phone:	*
8.	Business Phone:
9.	Mobile Phone:
10.	Best Number to Call:	Please select one Home Business Mobile *
11.	Best Time to Call:	*
12.	Where did you hear about us:	Please select one Search Engine C28 Franchising Website C28 Store Website Visited one of our stores On C28 Mailing List On C28 Email List Referred by friend/family Other *
	Work History
13.	Name of Employer or Company you own:	*
14.	Position/Title:	*
15.	Number of Years:	*
16.	Who will run the daily operations?:	Please select one Myself Someone else
	Primary City or Market of Interest
17.	First Choice (City, State):	*
18.	Second Choice (City, State):
19.	Third Choice (City, State):
20.	Number of Stores Interested in:
21.	Are you interested in a Master development market?	Please select one Yes, 3 stores Yes, 6 stores No Not sure
22.	Timeframe for Opening Store(s):	Please select one 0-6 Months 6-12 Months over 12 Months *
	Faith
23.	Your Current Church:	*
24.	Church Affiliation:
25.	Church pastor or elder name reference:
26.	Church Activities involved in:
27.	Ministries involved in:
28.	Your Testimony:
29.	Reason you want to open store(s)
	Financial
30.	Amount of liquid assets:	Please select one Less than $500k $500k - $1 million $1 - $2 million $2 - $5 million $5 million or more *
31.	Current Net worth?	Please select one Less than $500k $500k - $1 million $1 - $2 million $2 - $5 million $5 - $10 million $10 million or more *
32.	Amount willing to invest 1st year:	Please select one Less than $500k $500k - $1 million $1 - $2 million $2 - $5 million $5 - $10 million $10 million or more *
33.	Amount willing to invest 2nd year:	Please select one Less than $500k $500k - $1 million $1 - $2 million $2 - $5 million $5 - $10 million $10 million or more *
34.	Comments: