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PROSPECTIVE QUESTIONAIRE

213 N. Orange St.
Suite A
Glendale, CA 91203
Tel: (818) 546-1212
Fax: (818) 507-0118
* Required Field

ADDRESS APPLYING FOR (include unit #)*:



Please complete in full. This form does not obligate either party to the performance of a contract for leasehold property. It is purely to gather information and does not constitute an offer to lease property, or any negotiation for such purpose.

PERSONAL INFORMATION

Applicant
Name*:
Home Address*:
City*:
State*: Zip*:
How long at present address?:
E-mail address*:
Home Telephone:
Cellular Number:
Business Telephone:
Social Security Number*:
Driver's License No.:
Mother's Maiden Name:
Birth Date*:
Have You Ever Filed For Bankruptcy?:
Are You a U.S. Citizen?:
Co-Applicant / Spouse
Name:
Home Address:
City:
State: Zip:
How long at present address?:
E-mail address:
Home Telephone:
Cellular Number:
Business Telephone:
Social Security Number:
Driver's License No.:
Mother's Maiden Name:
Birth Date:
Have You Ever Filed For Bankruptcy?:
Are You a U.S. Citizen?:


EDUCATIONAL BACKGROUND

Applicant
High School:
Last Grade Completed:
College/University:
Major:
Degree Received: Year:
Co-Applicant / Spouse
High School:
Last Grade Completed:
College/University:
Major:
Degree Received: Year:


EMPLOYMENT / BUSINESS DATA

Applicant
Current Employer:
Address:
City:
State: Zip:
Position:
Present Salary (Gross Monthly):
Co-Applicant / Spouse
Current Employer:
Address:
City:
State: Zip:
Position:
Present Salary (Gross Monthly):


How will you operate your new business at the proposed location? Who will manage? How many employees will you have?

What type of merchandise, food and/or services will you be providing at this location? If you plan on operating a restaurant, please provide a sample menu with pricing. If you operate a retail store, please list brand names and price ranges.

What is your experience at operating such an enterprise? Please provide specifics as to dates, time, and locations as it relates to your experience.

What improvements do you plan to make to the premises (fixtures, carpet, etc.), and at what cost? How will you pay for these improvements?

Describe your anticipated start-up operating expenses at the new location and list amounts (include inventory, supplies, initial payroll costs, insurance, signage, etc. and attach additional sheet if more room is required to answer these questions).
$
$
$
$
Total Start-Up Expenses: $


Financial Information

ASSETS (I or We Own)

AMOUNT

Cash (checking) Acct. #
Amount
Name of Bank
 
Cash (savings) Acct. #
Amount
Name of Bank
 
Cash (other) Acct. #
Amount
Name of Bank
 
Accounts Receivable:
Stocks and Bonds (please list below):
Notes Receivable:
Cash Value Life Insurance:
Auto Year and Make 1
Amount
Auto Year and Make 2
Amount
Other Assets (describe)
Amount
Household Goods
Amount
Real Estate (please list below):  
Property 1 Address
Amount
Property 2 Address
Amount
Property 3 Address
Amount
   
TOTAL ASSETS: $
NET WORTH (Assets Minus Liabilities) $
   

MONTHLY INCOME

AMOUNT

Salary Gross - Applicant:
Salary Gross - Spouse:
Securities Income:
Rental Income:
Other Income (describe):  
Other Income 1
Amount
Other Income 2
Amount
Other Income 3
Amount
   
   
   

TOTAL INCOME:

$
Net Cash Income (Income minus Expenses) $
-

LIABILITIES (I or We Owe)

Amount

Notes Payable to Bank
Amount
Notes Payable to (Other - Give Name)
Amount
Accounts Payable to (Give Name):  
Name 1
Amount
Name 2
Amount
Name 3
Amount
Name 4
Amount
Taxes Payable:
Amount Owed on Real Estate:
Other Liabilities:
Other Liability 1
Amount
Other Liability 2
Amount
Other Liability 3
Amount
   
   
   
   
   
   
TOTAL LIABILITIES: $
   
   
MONTHLY EXPENSES AMOUNT
Real Estate Payments:
Rent:
Income Taxes:
Insurance Premiums:
Property Taxes:
Alimony, Child Support or Separate Maintenance:
Other (include installment payments other than real estate):  
Other 1
Amount
Other 2
Amount
Other 3
Amount
   

TOTAL EXPENSES:

$
   

STOCKS AND BONDS

Number of Shares/Amount of Bonds Description Name(s) of Owner(s) and How Held Current Market
logo 213 N. Orange St.
Suite A
Glendale, CA 91203
Tel: (818) 546-1212
Fax: (818) 507-0118

Please make sure to complete the Financial Information section. If you have a different format which was prepared by your accountant, it will be acceptable by the landlord in lieu of our financial statement. If you are signing the lease as a corporation, please include corporate information as well. In addition, please include copies of your last two years tax returns.

It is understood that the purpose of this application is to gather general information for the purpose of procuring the establishing credit from time to time with you and to induce you to permit the undersigned to become indebted to you and is in no way binding upon either Specialized Realty, Inc. or its agents or representatives of the applicant. It is, however, understood that the applicant supplies the information contained herein to the best of his or her knowledge and ability.

By submitting this application electronically, I/We hereby authorize Specialized Realty, Inc. or whomever they may appoint, or any Landlord, credit bureau, other investigation agency, or other financial institution, to investigate criminal background, credit history, financial responsibility, ability to pay rent, residential history, and the references and statements submitted to obtain information regarding my/our employment and background, as needed to process our application. It is understood that a non-refundable $35 application processing fee is required per applicant. This application shall become a part of any lease for this unit.

The undersigned certifies that the above statements (or in lieu thereof, the attached statement, as the case may be) and supporting schedules, both prints and written, give a full, true and correct statement of the financial condition of the undersigned as of the date indicated.

Applicant Name: Date
Co-Applicant Name: Date


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