Applicant's Name McDonald's USA, LLC Application for a Franchise Confidential This application does not obligate either party in any manner. I submit the following information as my complete and true personal and financial condition as of the date shown below. In accordance with the Privacy Act (5 U.S.C. 552 a), Freedom of Information Act, I expressly authorize any past or present employer, any law enforcement agency, federal, state or local, or any person who has personal knowledge of my character, work experience or criminal records to release this information to McDonald's USA, LLC (“McDonald’s”). I understand and acknowledge that, as a condition of being considered for the McDonald's franchisee training program, I must submit to a credit history check and criminal background check to be performed by a third party entity of McDonald's choice. The purpose of these checks is purely commercial in nature, in furtherance of a potential commercial business relationship between McDonald’s and me. I understand McDonald’s may use those results of the credit history and criminal background check in determining whether I will be placed into the franchisee training program or remain in McDonald's franchisee training program. McDonald’s does not seek and will not use the results of these checks for any other non-commercial purpose. If requested by McDonald's, I agree to supply statements from my professional advisors (i.e., banker, broker, accountant or attorney) verifying the above assets, and I also agree to furnish copies of federal income tax returns as filed for the last five years. I understand that McDonald's is relying upon all the above information as a material factor in considering my application to become a McDonald's franchisee, and I therefore agree to promptly notify McDonald's of any material change in any of the above information or any subsequent information provided to McDonald's. In addition, I release all persons from liability as a result of true, accurate information. I also certify that neither I nor any of my funding sources is, or has ever been, a terrorist or suspected terrorist, or a person or entity described in Section 1 of U.S. Executive Order 13224, issued September 23, 2001, as such persons and entities are further described at the Internet website www.ustreas.gov/offices/enforcement/ofac. I agree to comply with and/or to assist McDonald’s to the fullest extent possible in McDonald’s efforts to comply with the above Executive Order. Signature (Applicant) Date Signature (Spouse) Note: Use the "tab" key to navigate to the next field. Typed applications are preferred, versus hand written, to ensure we are able to read your information. Also, numeric fields asking for a "total" will be automatically calculated, however, you should verify the information is correct. Date Page 2 of PERSONAL INFORMATION Name Primary phone Residence Secondary phone E-Mail Address City State Zip code How long at this address? Spouse's name Previous Address: Have you ever been convicted of a felony within the past 7 years, or convicted of a felony that has resulted in your release from prison in the past 7 years, that has not been sealed, expunged, annulled, erased, pardoned or otherwise removed from your conviction record? Has any judgment ever been entered against you or your company or your employer where you were one of the litigants? Do not consider juvenile or youthful offend convictions when responding to this question. If yes, explain. Have you or your spouse ever declared personal bankruptcy? If yes, explain. Are you or have you ever been a sex offender registered with any federal, state or local government agency, including any listing on a public website? If yes, explain. Are you authorized to work in the United States as a McDonald’s franchisee? YES NO Are you fluent in another language? Are you fluent in another language? YES YES NO NO If YES, which language? EDUCATION Last year of school completed Name of college and/or postgraduate school Degree BUSINESS EXPERIENCE Present occupation Position Company Address Dates employed Describe duties, number of employees supervised and responsibilities Manager Name Manager Phone May we contact for a reference? Previous business experience (List most recent first.) Occupation Position Dates Employed Company Address YES NO Reason left Describe duties, number of employees supervised and responsibilities Manager Name Occupation Manager Phone Position Company May we contact for a reference? YES NO Dates Employed Reason left Address Describe duties, number of employees supervised and responsibilities Manager Name Manager Phone Have you ever owned your own business or franchise? If so, explain. Have you ever had a business failure? If so, explain. May we contact for a reference? YES NO Page 3 of PROFESSIONAL EXPERIENCE: Below are a number of areas related to your professional experience. Please select the level of experience you have in each area, and briefly describe the experience. No experience in this area Limited experience Skilled Highly Skilled Expert in this area 1 2 3 4 5 How would you describe your level of experience in: Recruiting and training successful work teams. Briefly describe your experience in this area. 1 2 3 4 5 Creating and implementing business plan with short and long term goals. Briefly describe your experience in this area. 1 2 3 4 5 Thriving in a customer centric environment. Briefly describe your experience in this area. 1 2 3 4 5 1 2 3 4 5 Managing teams in a fast paced, high pressure work environment. Briefly describe your experience in this area. 1 2 3 4 5 Working in a highly standardized operational environment. Briefly describe your experience in this area. 1 2 3 4 5 Full financial responsibility for results of a business unit, including capital investment decisions. Briefly describe your experience in this area. Page 4 of PERSONAL FINANCIAL STATEMENT INCOME STATEMENT FOR 12 MONTH PERIOD ENDING ___________________________________ Salary, wages, bonus, commissions Dividends, interest Other income - specify source, e.g., business profits (self-employed), trust, spouse, etc. TOTAL $0 Please provide details on the following asset verification schedules (schedule numbers in parentheses). Assets Cash on hand and in banks Vested profit sharing Securities, Bonds/debentures (1) Notes, accounts and mortgages receivable (2) Real estate-current market value (6) Net value of business interests (7) Other-automobiles and other personal property, etc. (4) Total assets Liabilities Loans/notes/accounts payable (3) Real estate mortgages (6) Other debts or obligations (5) Total liabilties Total Assets Net Worth (Assets less liabilities) $0 $0 $0 $0 ASSET VERIFICATION SCHEDULES (1) Listed securities, bonds/debentures No. shares Description Pledged (yes/no) Current mkt. value TOTAL $0 (2) Notes/accounts/mortgages receivable Debtor Relation to applicant Maturity date Nature of debt Original face value Monthly payment Total $0 (3) Loans/notes/accounts/bills payable (excluding mortgages) Relation Lender to applicant Nature of debt Secured Maturity yes/no date Original face value Monthly payments Total Interest rate Present balance $0 (4) Other Assets (e.g., stock options, cash value of life insurance, automobiles and other personal property, etc.) Current fair Description market value Total Present balance $0 (5) Other debts and liabilities (e.g., insurance loans, alimony, child support, leases, contracts, legal claims, judgments, chattel mortgages, taxes, comaker or guarantor, etc.) Obligee Total Description Amount Page of ASSET VERIFICATION SCHEDULES-- Continued (6) Real estate Address and description of property (residential, rental, Date Title in vacant) acquired name(s) of Original Cost Original mortgage amount Mo. payments (incl. taxes, assessments) Total Current market value $0 (7) Business Interests Name and address of business Description Type (partner, corp., sole) Names of all owners Relation to applicant Percent equity Buy/sell agreement yes/no Current mortgage balance $0 Net Value $0 Valuation method Net value your interest Total Does your spouse or another person have any interest in any of the above assets? If yes, please explain and list assets. Have any of the above assets been acquired by you as a gift? If yes, specify assets, from whom and when. MISCELLANEOUS INFORMATION List any hobbies, community activities, special interests or other pertinent information Are you related by blood or marriage to any officer of McDonald's USA, LLC? YES NO Name Relationship Are you or your employer providing products, goods or services to McDonald's or franchisees of McDonald's? If yes, please attach detailed information. Will you devote your full time to this business? YES NO The flexibility to relocate may be required. To which general geographic area(s) would you be willing to relocate for a restaurant opportunity (i.e., Northwest, Southwest, Midwest, Northeast, Southeast)? Have you ever worked in a McDonald's restaurant? If so, where and when? YES NO Have you ever applied for a McDonald's franchise? If so, where and when? YES NO Personal references (other than employers or relatives): Name in full Relationship Company / Occupation Years known Phone # Name in full Relationship Company / Occupation Years known Phone # Name in full Relationship Company / Occupation Years known Phone # U.S. Application Form.doc. 5/24/2017 11/30/2016
