| ROUTE SALES DISTRIBUTORSHIP INFORMATION REQUEST To Print, set all 4 margins to 1/2 inch (.5 inch). Print page 1 only. |
| Personal Information: |
| Home Address: City State Zip |
| Phone Day Night Cell ( ) ( ) ( ) |
| Marital Status: Spouse?s Occupation: |
| Do you have a valid driver's license? Yes No Valid Driver's License is Required. |
| Have you ever been convicted of a felony? Yes No If yes, please explain: |
| What is your timeframe for starting a business? <3 months 3 to 6 months 6 months > |
| What is your preferred route location (city): |
| Education: |
| High School Name & Address No. of Years Year Graduated |
| College Name & Address No. of Years Year Graduated |
| Trade/Other Schooling No. of Years Year Graduated |
| Financial Information: |
| Assets: Liabilities |
Cash in Checking/Savings: Mortgage Balance: |
Stocks/Bonds/Funds/CDs: Vehicle Loans: |
Other Real Estate: Other Loan Balances: |
Vehicle / Other Value: |
TOTAL ASSETS: TOTAL LIABILITIES: |
| Employment Information: |
| Current Employer: Address: |
| Date Started: Your Position: Annual Income |
| Signatures and Permissions: |
| Office Use Only |
CrdtC:__________Score:___________Agency___________CrimC:_____________ DSDE___________ |
| Qualified: Yes No |
| DSD Merchandising, Inc. 4570-H Alvarado Canyon Rd. San Diego, CA 92120 877-280-2611 FAX (619) 280-2699 |
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Home Market Value: Credit Card Balances: |
| Last: First: Middle: Social Security #: |
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| I certify that the information I have provided is complete and correct. I hereby authorize DSD Merchandising to conduct a credit check and a criminal records check to obtain verification of any of the above information. |
Signature Date |
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