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Name	:
Address	:
Identity card number	:
Phone	:
Mobile phone	:
E-mail^*	:
Business Information
Current occupation	:
Have you ever been a franchisee before?	:	Yes No
If Yes, detail information (Brand / Location)	:
Do you currently have a location or retail space for franchisee outlet?	:	Yes No
Do own the outlet?	:	Yes No
If yes, details (location/size/available date)	:
How much capital do you intend to invest in the franchise?	:
When you can start the franchise operation?	:

Any information on this form will be kept strictly confidential. Columbia will use the information provided on this form for the sole purpose of evaluating prospective franchisees, and will not sell or provide this information to any party without the written consent of the applicant. The information contained in this statement is provided for the purpose of obtaining a franchise rights to use the trade name, methods and other intellectual property of Columbia. Columbia is authorized to make all inquiries they deem necessary to verify the accuracy of the statement made herein.