Introductory Questionnaire

First Name:*				Last Name:*
Spouse First Name:				Spouse Last Name:
Date:
Street Address:*
City:*
State:*		Select a State ------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming		Zip:*
Country:		Select a Country ------------------- Algeria Angola Argentina Aruba Australia Austria Bahamas Bahrain Bangladesh Belgium Bolivia Botswana Brazil Bulgaria Cameroon Canada Caribbean Central African Republic Chile China Colombia Costa Rica Croatia Cyprus Czech Republic Denmark Dominica Dominican Republic Ecuador Egypt El Salvador Estonia Ethiopia Finland France Gabon Georgia Germany Ghana Greece Guatemala Honduras Hong Kong Hungary India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kenya Korea Kuwait Latvia Lebanon Libya Lithuania Macedonia Malawi Malaysia Mauritius Mexico Morocco Mozambique Namibia Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Romania Russia Saudi Arabia Serbia Singapore Slovenia South Africa South Korea Spain Sudan Suriname Sweden Switzerland Taiwan Thailand Trinidad Tunisia Turkey Uganda UK Ukraine United Arab Emirates Unknown Uruguay USA Uzbekistan Venezuela Vietnam Yemen Zaire Zambia Zimbabwe
Daytime Phone:*
Cell Phone:*
Email Address:*
Date of Birth:
Are you currently or have you ever been a partner or owner of a business?		Yes No
If so, when?
Please Describe:
List your hobbies and special interests:
Are you a citizen of the U.S.?		Yes No
Do you have any friends or family who are Interim HealthCare franchisees?		Yes No
If yes, describe:
Name of current employer and your position?
List three cities or states (in order of preference) where you might like to consider owning an Interim franchise:
Approximate household income (yours and your spouse's combined):		$
Have you or your spouse filed bankruptcy in the past seven years?		Yes No
Have you ever been convicted of a felony?		Yes No
Reply ID:		Your Reply ID can be found in the lower right corner of the letter you received which provided this web address.

Disclosure and Authorization of Investigation

All statements in this questionnaire are true and correct; I have no material outstanding obligations except as shown in this Questionnaire and no undisclosed law suits or judgments pending or entered against me. I understand consumer reports may be requested from consumer reporting agencies in connection with this Questionnaire. I understand the investigation may include obtaining information regarding my creditworthiness, credit standing and credit capacity. I hereby authorize Interim HealthCare, Inc. to obtain a consumer report or make other inquiries about the information described herein and hereby release Interim HealthCare, Inc., its employees, representatives and agents from any liability as a result of the reporting of such information.