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To learn more – and to help us conduct a preliminary assessment of your qualifications for becoming a Clean Start Systems franchisee, please complete and submit the following form. We will respond to ALL submissions promptly!

Part I. General Information

First Name*

Last name*

Address

Home phone

Business phone

Cell phone

Email*

Preferred means of contact

Home phone

Business phone

Cell phone

Best time to call

Desired area for franchise

Second choice of location

Part II. Other

Have you ever owned or do you presently own a business? If so, please give details

Have you ever made application for a bond which was refused?

Have you ever filed for bankruptcy, had a real estate loan foreclosed, or had any liens against you? If yes, please explain

Have you ever been or are you now a party to any lawsuits? If so, please explain

Have you ever been convicted of any offense? Include traffic violations for which you were fined $50 or more. If so, explain in full, including date, charge, place, under what name and action taken

I understand that the information provided is confidential and affirm that it is true to the best of my knowledge. I understand that providing this information does not obligate me to purchase a franchise, nor does it obligate the franchiser to offer a franchise to me.

Signature

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Currently, (1) This franchise is not being offered to residents of the states listed below; (2) This franchise offer is not directed to any person in the states listed below by or on behalf of the franchisor or anyone acting with the franchisor’s knowledge, and (3) No franchise will be sold in the states listed below by or on behalf of the franchisor until the offering has been registered and declared effective and a Franchise Disclosure Document delivered to the prospective purchaser in compliance with each state’s franchise law.

California
Connecticut
Hawaii
Illinois
Indiana
Kentucky

Maryland
Michigan
Minnesota
Nebraska
North Dakota
Rhode Island

South Dakota
Texas
Utah
Virginia
Washington
Wisconsin

Filling out and submitting this questionnaire is only a starting point in our respective analysis as to whether we should enter into a franchise relationship. Consequently, your submission of this questionnaire is for information purposes only. This questionnaire is not an offer to sell or a solicitation of an offer to buy a franchise. No sale will occur prior to the execution of a Franchise Agreement and the payment of all required fees by you. Neither our acceptance of this questionnaire nor any discussions resulting therefrom constitute any commitment on our part to enter into any agreement to sell a franchise.

Part I. General Information

Part II. Other

We can be reached by phone at 888-626-1722 or via email through our website’s secured contact form.