Licensing Application

The following Information is the basis for my Trademark Licensing Application. The submission of this application does not obligate Quickly Corporation or me in any way or manner. (Please print or type all information requested. Additional paper should be attached if needed.)

Name      _____________________________________________________
                             First                  Middle                    Last

Address___________________________________________________________________
                                   Street                              City                  State         Zip

Driver's License No.__________________________ 

Social Security No.___________________________
Residence Telephone (     )_____________________ 

Best Time to Call: ________am  _______pm

PERSONAL INFORMATION

Date of Birth______________   Marital Status______________
Spouse's Name______________   Spouse's Occupation______________
Spouse's Date of Birth______________   

Spouse's Social Security No.______________
Number of Dependents______________   Age of Dependents______________
Last former
residence__________________________________________________
I am a citizen of_________________   

I have permanent residence rights in____________________
My immigration Status, if applicable, is____________________________________
(Please attach copies of supporting data.)

Have you ever been convicted of a felony or misdemeanor or are such charges pending, being appealed. or are you under indictment? (Do not include minor traffic violations)    YES    NO

Have you ever been adjudicated bankrupt?    YES    NO

Are you or your employer providing products, goods or services to Quickly or any of its licensees?    YES    NO

If you answered "yes" to any of the above, please provide details on a separate sheet.


BUSINESS EXPERIENCE - Present Employment

Company:____________________________________
Position:______________________________________
Address:______________________________  

Employed From: ______________to______________
Annual Salary:___________________________
Supervisor:__________________________________
Telephone:(    )_____________________
Describe duties, responsibilities and number of employees supervised:
___________________________________________________________________________
___________________________________________________________________________
May we contact your present employer?    YES    NO
May we contact you at your business?    YES    NO

Please attach a resume of your previous experience.


EDUCATION

State your educational experience, including name and location of schools, years completed and degrees earned.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

BUSINESS INTEREST

To what extent will you be actively involved in the day-to-day operations of the restaurant?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What percent of the equity of this restaurant business will you own?____________%
What amount of cash will you personally invest in this business?
$__________________________________
What is the source of these funds?
___________________________________________________________________________
___________________________________________________________________________
Will you have a business partner(s)?    YES    NO
If you have a business partner, who will be the Operating Partner?___________________________
What is the total amount of cash your business partners will vest in this business?
$_________________________
Will any partners interest in the franchise be encumbered in any way or subject to an agreement between partners? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
Will any person or entity other than the partners be entitled to receive, directly or indirectly, part of the profits from the operation of the restaurant? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________

Please list business partners:

              Name                 Estimated Net Worth         %         Proposed Investment

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1)___________________  ____________________  ________  _____________________
2)___________________  ____________________  ________  _____________________
3)___________________  ____________________  ________  _____________________
4)___________________  ____________________  ________  _____________________
Do you currently have an interest in a fast food business or any other business ventures? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
If you are approved for a Quickly Trademark License, will any partner be involved in any non-Quickly business activity? (This includes all business activities, not just restaurants) (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
Will the Operating Partner receive income from any source other than the restaurant? (If so, please describe)
___________________________________________________________________________
___________________________________________________________________________
What are your location preferences?
___________________________________________________________________________
___________________________________________________________________________

NOTE: Separate application and financial statements are required of each partner/owner.

The undersigned certifies that the information furnished in this Quickly Trademark Licensing Application is true, correct and complete. I also authorize Quickly USA to make any additional credit/character checks which it deems necessary, and to release to prospective financing sources such financial and other information concerning me (us) in its files as may be requested.

Dated:_________________, 200___

Applicant Name:_________________________    Signature:_________________________________

Spouse Name:_________________________    Signature:_________________________________

PLEASE ENCLOSE A COPY OF A PROFESSIONALLY PREPARED FINANCIAL STATEMENT.

@

Please print it and fax to 510-780-1008. Attention: Trademark Licensing Department




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