Canadameds.com - Preliminary Affiliate Contact Business Information Form

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Preliminary Affiliate Contact Business Information Form
Upon completion of our Preliminary Affiliate Contract Business Information Form, please include a detailed Business Plan outlining the following; 1. Indicating your organization as a L.L.C. (Limited Liability Corporation) 2. Directors (other than oneself) named in L.L.C. (* personal bio. to be included for all parties named in L.L.C.) 3. Physical Location of storefront and or location currently negotiating 4. Revenue / Budget Projections for: 6 months, 12 months. Please complete and return both Business Information Form and Business Plan via fax to: (204) 987-3003.
Applicant Details: Please complete this application in detail. All information will be held in the strictest confidence.
Date:
Applicant's Full Name:
Residential Address:
City:
State:
Zip Code:
Country:
Phone (daytime):
Phone (evening):
Date of Birth (year/month/day):
Applicant's Education Level:	Elementary School
	High School
	University
	Other
(If Other, please explain)	Not Applicable
Your e-mail address:
Best time to reach you:	AM PM
How would you like us to contact you:	Phone Email
Questions or Comments:
Employment
Current Business or Employment:
Name of Company:
How Long There:
Nature of Business:
Position or Job Title:
Description of Type of Work and Key Areas of Responsibility:
Financial Information To be completed on behalf of the applicant and spouse.
Your Assets
Cash in bank(s):
Value of home, if owned:
Other properties:
Savings:
Shares and bonds:
Vehicles:
Your own business (sales value):
Money due to you:
Other Assets:
Total Assets:
Your Liabilities:
Notes Payable:
Owing on house:
Owing on other property:
Owing on Vehicles:
Credit card debt:
Other Obligations:
Total Liabilities:
During the last 8 years have you ever:
Declared bankruptcy?	Yes No
Been a director of a company that has gone into liquidation?	Yes No
Had any legal judgment entered against you?	Yes No
Been refused a bank loan?	Yes No
If you answered yes to any of the above, please give details:	Not Applicable
Other Information:
How long have you been seeking a business?
Other businesses being considered, if any?
Do you plan to have a financial partner?	Yes No
If yes, will he/she be active?	Yes No
Do you plan to have investors?	Yes No
If yes, to what extent?	Not Applicable
When would you be able to start work in your own business?
I declare the information in this application to be true and complete to the best of my knowledge.
Signature: Date:

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All prescriptions are dispensed by:
Point Douglas Pharmacy
881 Main Street
Winnipeg, Manitoba
Canada R2W-3P2

Licensed by:
The Manitoba Pharmaceutical Association - Lic.# 32252

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