Today's Date:

First Name:

Middle Name:

Last Name:

Citizen of:

Date of Birth:

Identification or Social Security Number:

Home Telephone Number:

Mobile Telephone Number:

Fax Number:

Email Address:

Address:

City:

State:

Zip:

Are you of legal age in your state/province and/or area of residence? Yes No

Have you ever been convicted of a felony? Yes No

Have you ever been associated directly or indirectly with terrorist activity? Yes No

First Name:

Last Name:

Citizen of:

Date of Birth:

Identification or Social Security Number:

Are you of legal age in your state/province and/or area of residence? Yes No

Have you ever been convicted of a felony? Yes No

Have you ever been associated directly or indirectly with terrorist activity? Yes No

High School Two-Year Degree Four-Year Degree Graduate Degree

Employed by:

Your Title:

Nature of Business:

Address:

City:

State:

Zip:

Telephone Number:

Name:

Telephone Number:

Address:

City:

State:

Zip:

Name:

Telephone Number:

Address:

City:

State:

Zip:

Name:

Telephone Number:

Address:

City:

State:

Zip:

Income from present occupation:

Other income:

If other income, explain:

Bank Name:

Branch:

Address:

City:

State:

Zip:

Bank Name:

Branch:

Address:

City:

State:

Zip:

Bank Name:

Branch:

Address:

City:

State:

Zip:

Would this business be your sole source of income? Yes No

Own home or rent? Rent Own

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 invest in your franchise?

Would you be the sole owner of this business? Yes No

Will you have other partners/owners? Yes No

Do you intend to run this business yourself? Yes No

If no, who:

Estimated training date if you should choose to invest:

Butterfly Life location preference? 1.

Do you or anyone in your immediate family own an interest in a health club, fitness club, or weight loss center? Yes No

If yes, please describe:

Are you or anyone else in your family currently under any form of non-competition agreement that limits your right to operate any business? Yes No

Are you a citizen of a country which is currenty prohibited, by law, executive order or otherwise, from conducting business with or owning a business in the United States? Yes No

Have you ever filed for bankruptcy protection Yes No