Phone: 800-954-3053
Email: info@captshrimp.com



 
 
Application for Additional Information
The filing of this form does not obligate the applicant to purchase or the franchisor to sell a franchise.
Complete in full and do not use abbreviations. Please print clearly or type.

 Note: Fields denoted with a * are mandatory.
 
E-mail Address 
Name 
Address 
City  
State 
Zip

Phone Number

 (area code/country & city code)

Mobile 

 (area code/country & city code)
 Fax 
(area code/country & city code)
Where did you hear about the CAPT. SHRIMP® franchise ?   
  *       *
  * Citizen of 
  * Date of Birth   
 
  * Tax ID/Social Security Number 
  * Gender       Other names known by 
  * Are you of legal age in your State/Province/Residence Area ?
  * Have you ever been convicted of a felony ?   
  * Have you ever been associated directly or indirectly with terrorist activities ?  
  * Have you been involved in any litigation proceeding within the last 5 years ?     
     (If yes, additional information will be required at the time of sale)

 
Spouse Personal Information  (Use A Separate Application for Partners)
 		  
First Name     Last Name      Middle Initial   
   Citizen of 
  
   Date of Birth     
 
   Tax ID/Social Security Number    
   Gender           Other names known by   
   Are you of legal age in your State/Province/Residence Area ? 
   Have you ever been convicted of a felony ?   
   Have you ever been associated directly or indirectly with terrorist activities ?   
   Have you been involved in any litigation proceeding within the last 5 years ?      
   (If yes, additional information will be required at the time of sale)

 
Educational Background
* Highest Education Achieved   
 
  Schools Attended   Years   Grade or Degree Attained
  *   *   *
     
     

 
Business Information  (Complete All Questions)
 *  
  * No. Years              * Nature of Business 
  Title 
  Describe Position 
  * Street Address/P.O. Box 
  Suite/Apartment # 
  * City          State/Province 
  * Zip/Postal Code        * Country
  *
Telephone (Bus.)     Telephone (Alt.) 
  (area code/country & city code)      (area code/country & city code)
  * Select Your Business Experience Level 
  * May we contact you at work ?     

 

Financial Information  (Please List Figures in US Dollars)

  
*   Income from current occupation   /year  
  Income from other sources   /year  
  Please explain other income    
 
  Personal Bank(s) Branch Address
     
 
 
 
  * Individual Liquid Assets (Cash, Stocks, etc.)  a)  
  * Individual Fixed Assets (Home, Car, etc.)  b)  
  * Individual Total Assets  (a+b) c)  
  * Individual Liabilities (Mortgages, Loans, etc.)  d)  
  * Your Individual Total Net Worth  (c-d) e)  
      (Excluding any financing listed below.)  

 
 
  * Would this business be your sole income source ?
  * Is there other financing not included in (e) above ?
     If yes, how much financing is available ? 

 
References  (Excluding Relatives)
Name   Address   Telephone (area code/country & city code)
  *   *   *
     
     

 
Restaurant Operations
 * If qualified, when will you invest in a franchise ? 
  * How involved will you be in operating the restaurant ? 
 
     Preferred Geographic Franchise Area
     1st Pref.   
     2nd Pref. 
  * Estimated training date should you choose to invest: 

 
Disclaimer
 
I understand that the granting of a franchise is at the sole discretion of the Franchisor CAPT. SHRIMP CORP.

I understand that any information I receive from the Franchisor or from any employee, agent or  franchisee of the Franchisor is highly confidential ("Confidential Information"), has been developed with a great deal of effort and expense to the Franchisor, and is being made  available to me solely because of this Application. I agree that I shall treat and maintain all Confidential Information as confidential, and I shall not, at any time, without the express written consent of the board of directors of the Franchisor, disclose, publish, or divulge any Confidential Information to any person, firm, corporation or other entity, or use any Confidential Information, directly or indirectly, for my own benefit or the benefit of any  person, firm, corporation or other entity, other than for the benefit of the Franchisor.

I authorize the procurement of an investigative consumer report, a general background search and an investigation in accordance with anti-terrorism legislation, such as the USA Patriot Act and Executive Order 13224 enacted by the US Government (collectively referred to as "Investigations"). I understand that these Investigations may reveal information about my background, character, general reputation, mode of living, association with other individuals or entities, creditworthiness, litigation history and job performance. I understand that, upon written request, within a reasonable period of time, I am entitled to additional information concerning the nature and scope of these Investigations. I hereby release a representative of the Franchisor, a credit bureau, security consultant or other investigative service provider selected by the Franchisor, its officers, agents, employees, and/or servants from any liability arising from the preparation of these Investigations.

This authorization for release of information includes but is not limited to matters of opinion relating to my character, ability, reputation, association with others and past performance. I authorize all persons, schools, companies, corporations, credit bureaus, law enforcement agencies or other investigative service providers to release such information without restriction or qualification to a representative of the Franchisor, a credit bureau, security consultant or other investigative service provider selected by the Franchisor and any of its officers, agents, employees and/or servants. I voluntarily waive all recourse and release them from liability for complying with this authorization. This authorization/release shall apply to this as well as any future request for these Investigations by the above named individuals or entities. I authorize that a photocopy or facsimile of this release be considered as valid as the original.

I agree that I will settle any and all previously unasserted claims, disputes or  controversies arising out of or relating to my application or candidacy for the grant of a CAPT. SHRIMP® franchise from Franchisor, exclusively by final and binding arbitration at a hearing to be administered by a neutral arbitrator in accordance with the Commercial Rules of the American Arbitration Association and to be held at Lauderhill, Florida USA, unless my local laws require otherwise. Such claims include, but are not limited to, claims under federal, state, provincial or common law, such as employment law, civil rights law, contract law and tort law.

Everything that I have stated in this application is true and I understand that the information provided by me will be relied upon by the Franchisor. In accordance with anti-terrorist legislation, I understand that I will not be approved to purchase a franchise if I have ever been a suspected terrorist or associated directly or indirectly with terrorist activities. I read, understand, and agree to all of the above. Additionally, I understand that the Franchisor may require me to pass a standardized Math and English exam, unless I fall under one of the exemptions set forth in the Franchisor's Offering Circular.
 

  
Signatures     * I have read the above disclaimer.  
Type name to indicate consent. Signature required at time of sale.      
 
  * Applicant's Typed Name
    		 Spouse's Typed Name
 
 
Please click the  Submit button when you are done filling out this form.

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