office (402) 502-6715

Willingham Health Services Franchise Systems, LLC.

Confidential Franchise Application Form

We would appreciate it if you would fill in this form to help us determine mutual compatibility and financial responsibility. The information will be kept confidential, and the submission of this form does not obligate WILLINGHAM HEALTH SERVICES FRANCHISE SYSTEMS, LLC or you in any way.

Personal Information
First Name Last Name
Additional Names
First Name Last Name
First Name Last Name
Home Address
City State Zip Code
Years at this address Do you own your own home?
Previous Address (if less than 2 years at current address)
Home Address
City State Zip Code
Years at that address
Residence telephone no. Business telephone no.
Social Security no. Spouse Name
Education (Highest level attained)
Special Schooling, and/or Training Seminars Attended

Personal References
Name Occupation
Address
City State Zip
Phone
Name Occupation
Address
City State Zip
Phone
Name Occupation
Address
City State Zip
Phone
Business Experience
Present or Previous Employer
Employer Name Employer's Address
City State Zip
Phone
Duties and Responsibilities
Dates Employed: From
To
Salary
Previous Employer
Employer Name Employer's Address
City State Zip Phone
Duties and Responsibilities
Dates Employed: From
To
Salary
Have you ever worked for a WILLINGHAM HEALTH SERVICES franchise?
If so, please provide details of employment.
General Information
How did you become interested in WILLINGHAM HEALTH SERVICES?

How much capital are you prepared to invest Do you have a source of financing?
If so, please name the source Type of entity we will operate as franchisee

If you plan to operate as a partnership, corporation, limited liability company, please list partners, shareholders, or members  
Partner/ShareholderStatus 
PrimaryIncompleteEdit Financial Info

I certify all information provided in this application, including financial data, is correct. By signing this application I authorize investigation, including preparation of credit reports, of all statements contained herin, and the financial information disclosed herin, and release all parties from any liability for any damage that may result from this investigation.

I authorize any person or company contacted to provide WILLINGHAM HEALTH SERVICES FRANCHISE SYSTEMS, LLC or its representative, all such information requested by WILLINGHAM HEALTH SERVICES FRANCHISE SYSTEMS, LLC , including, without limitation, information concerning my education, employment, work habits, observations of character, and credit history.