Make An Inquiry

Licensee Application

This request for consideration will help us evaluate your qualifications to be granted an Ormita Licensed Business. This is not an application. Should you qualify, we will request additional information. Please be sure to complete the entire form.

Personal Data

Name
Tax ID or Social Security #
Address
City
State
Country
Zip Code
Business Phone
Home Phone
Best time to call
Years at above address
Birth Date / /
Marital Status Single Married
Spouse's Name
Number of Dependents
Ages
Have you ever declared bankruptcy? Yes No
Have you ever been convicted of a felony? Yes No

Business Experience Present / Most Recent Position

Previous Position Title
Dates Position Held
Company Name
Type of Business
Most Significant Accomplishments

Additional Position

Previous Position Title
Dates Position Held
Company Name
Type of Business
Most Significant Accomplishments

Additional Position

Previous Position Title
Dates Position Held
Company Name
Type of Business
Most Significant Accomplishments
Have you ever owned a business? Yes No If yes, what type?

Business and Management Goals

Do you plan to devote full time to this business venture? Yes No
Will your spouse be active in the business venture? Yes No
Do you plan to have equity partners? Yes No
If yes, please identify all partners below (Name, Address, Telephone) 1
2
3
Active in Business? Yes No
License Agreement Requesting (check those interested in): Client Director Licensee Broker Licensee
Regional Licensee National Licensee
Planned date to open your Ormita Licensee Business: / /
City Preferences: 1st
2nd
3rd

Personal Information Please list figures in US dollars

Income from current occupation $ per year
Other Income $ per year
If other income, explain
Personal Bank Branch
Address
City/State/Province
Other Bank Branch
Address
City/State/Province
Other Bank Branch
Address
City/State/Province

Specific Data Please list figures in US dollars

Would this business be your sole source of income? Yes No
Own home or rent? Own Rent
If own, current value $
Mortgage $
Your total assets $
Your total liabilities $
Your net worth $
Amount of cash available for investment $
Do you have a financing source? Yes No
Amount of financing available $
If qualified, when would you be ready to start in your Licensed Business?
Estimated date you can begin training? / /

Other Information

Why do you believe you can successfully operate an Ormita Licensed Business?
What is motivating you to pursue this business opportunity (personal goals and objectives)?
Have you ever been a Member of a Trade / Barter Exchange? Yes No Exchange Name:
Have you ever owned or operated a Trade Exchange? Yes No
Are you current in your (and your business) tax obligations? Yes No
Have you ever sued or been sued? Yes No
Were you (or your business) ever subjected to a tax lien? Yes No

I agree to the above Terms and Conditions

TYPE YOUR FULL NAME HERE