Full Name:

Phone Number:

Email Address:

Geographical Area of Interest:

Address:

City:

Province:

Postal Code:

Please tell us a little about yourself:

1. Are you a business owner?
   Yes:    No:



2. Have you ever owned a business?
   Yes:    No:



3. How did you hear about Chem-Dry?
   

   	Website		yahoo.com
   	Franchise Solutions		Entrepreneur Magazine
   	Be the Boss		Franchise Handbook
   	Bus or Train		Canadian Franchise Association
   	Newpaper		Small Bus. Op. Mag.
   	Carpet Cleaned by Chem-Dry		Friend
   	Used Chem-Dry retail products		Talk Radio
   Other




4. Initially, would you plan to work?
   Full time:   Part time:



5. Would you have a partner in the business?
   Yes:    No:



6. How long have you lived in the area you would be operating the business?
   0-1 yr:    2-5 yrs:  5-10 yrs:  10+ yrs:



7. Would you consider moving if there wasn't a franchise available in your area?
   Yes:    No:



8. How soon would you like to be in business?
   ASAP:    1-3 mo.:  3-6 mo.:  6-12 mo.:



9. The initial investment for the Franchise is $18,950, plus a recommended $10,000 working capital. Is the money available to you, if we mutually agree this is the right opportunity?
   Yes:    No:



10. In which format would you like the introductory film?
    Video:    DVD:



11. What is the best time to reach you?
    Daytime:   Evenings:   Weekends: