Application

Nutrishop Application Form

THIS IS NOT AN APPLICATION FOR EMPLOYMENT. This is STEP 1 to obtaining additional information regarding opening a NUTRISHOP retail nutrition store.

Take the next step to learning more about the License Opportunities with NUTRISHOP^TM by filling out our Online Application. This is your first step to owning your own nutrition store. All of the information provided will be for the exclusive use of NUTRISHOP as part of the qualification process. All of the information provided will be held in the strictest of confidence. Completing this Online Application does not obligate either party in any manner. This is an easy 4-step application where all required fields will need to be complete before moving to the next page. Sections include: Personal Information, Work History, Cities/Territories of Interest and General Financial Information (we will never ask for you to transmit account numbers or other sensitive information via this form).

* = Required

Personal Information

First Name: *

Middle Name:

Last Name: *

E-Mail Address: *

Website (if any):

Street Address: *

City: *

State: *

Zip: *

Home Phone: *

Work Phone:

Cell Phone:

Best time to call:

Date of Birth: *

Are you a U.S. Citizen: *

yes

no

Marital Status: *

Married

Single

No. of Dependents:

Partner/Spouses Name:

Have you visited one of our stores?: *

yes

no

If you have visited a store, which store?:

How did you hear about the Nutrishop license program?: *

Business Experience / Work History

Primary Employment History (please list your last three positions)

From Date:

To Date:

Company:

Position Held:

Annual Salary:

From Date:

To Date:

Company:

Position Held:

Annual Salary:

From Date:

To Date:

Company:

Position Held:

Annual Salary:

Employment History (partner/spouse)

From Date:

To Date:

Company:

Position Held:

Annual Salary:

From Date:

To Date:

Company:

Position Held:

Annual Salary:

From Date:

To Date:

Company:

Position Held:

Annual Salary:

TOP 3 CITIES/TERRITORIES OF INTEREST

City, State or Region: *

Are you looking to relocate?: *

yes

no

If yes, where?:

Would you be involved in the business?: *

Part Time

Full Time

Are you interested in multiple locations?: *

yes

No

Would friends, family, partners be involved in the business?: *

yes

No

If yes, list name and relationship:

When are you planning to start your new business?: *

Please list any additional information regarding your business experience or skills.: *

Financial Information

As you learned from our FAQ page, it typically costs between $123k - $149K to open your own NUTRISHOP retail location. Are these funds currently available to you?: *

(If you would require a loan, please answer NO)

yes

No

Assets

Cash on hand & in banks:

Retirement Accounts:

Government Securities:

Securities:

Accounts and Notes Receivable:

Home:

Liabilities

Home:

Others:

List Bank Names for above notes:

Accounts & Bills:

Real Estate Mortgage Payable

Home:

Other:

Other Liabilities:

Total Liabilities:

Net Worth:

(Total Assets minus Total Liabilities)

All that I have stated in this personal financial statement is true to the best of my knowledge. I further understand that this application form is for the purpose of information only. It is not an offer to sell a license or business opportunity.*

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Verification Math Question: *

Math Question: * 1 + 1 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.