First and Last Name (*)


Mailing Address


Apt or Suite #

I
City, State, ZIP Code
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Home Phone


Work Phone


Cell Phone


Email Address


I'd prefer to be contacted by...
Email
Cell Phone
Home Phone
Work Phone

The best time to call is


Do you have any sales experience? (*) YesNo

Sales Type


Have you ever sold advertising? (*) YesNo

If approved, when would you like to begin training? (*)


How did you hear about CityNation's pre-franchising opportunity?

Educational Background

Highest Education Achieved
College Degree or Higher
Some College
High School/GED
Didn’t Complete High School

School Attended      Years (*) 1 2 3 4 5 6 7 8 9 10

Degree or Grade Attained 

School Attended      Years 1 2 3 4 5 6 7 8 9 10

Degree or Grade Attained

Current or Last Employment

Company Name


Nature of Business


Job Title


Number of Years with Organization (*) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+

Start Date         End Date

Company Address


City, State, ZIP Code
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Phone

Invalid Input

Franchise Operations

Your contact information (we insert this in your promotional literature)

Name



Email Address


Phone Number


Business Experience and Financial Information

Have you ever been involved with a franchise system? (*) YesNo

If so, list name and involvement:

Have you ever owned a business? (*) YesNo

Have you ever failed in business or filed bankruptcy? (*) YesNo

Are there any lawsuits pending against you? (*) YesNo

Are the funds required for this business available to you? (*) YesNo

Gross Income (*) $

Your Individual Total Net Worth (*) $ $100,000 or less $101,000-$200,000 $201,000-$300,000 $301,000+

Other Relevant Information

Please use this space to provide other relevant information or comments.



Confirm

By entering my name below, I verify that the above information is true and correct, and I hereby authorize the CityNation Publishing Company to investigate my background and credit history.

I also declare that all information I receive from CityNation Publishing Company regarding their pre-franchise advertising business opportunity will remain confidential, and that I will only disclose information to my immediate family and potential partners and/or investors. I understand that this application is not an offer and does not obligate me in any way to purchase a CityNation pre-franchise.