New Dealership-Application

Dealer Information
Name (First, Middle, Last)
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Business Phone
Cell Phone
Current Employer
Employer's Address
Current Position
Date of Employment (Start - Finish)
Date of Birth
Marital Status
- Married
- Single
Number of Dependents
Spouse's Name
Are You A U.S. Citizen?
- Yes
- No
Have You Ever Been Convicted of a Felony?
- Yes
- No

Form of Organization
Form of Organization
- Corporation
- Limited Liability Corporation
- Partnership
- Sole Proprietor
Date Incorporated (If legal entity has not yet been formed, put N/A)
Company Name

Principals and Management
Investor/Associates who will join you in this venture. Please have each fill out separate form.
Investor #1 Name
Investor #1 Address
Investor #1 % of Ownership
Investor #1 % of Time
Investor #2 Name
Investor #2 Address
Investor #2 % of Ownership
Investor #2 % of Time
Investor #3 Name
Investor #3 Address
Investor #3 % of Ownership
Investor #3 % of Time

Yearly Income
Minimum Liquid Assets/Net Worth: $200,000.00/$500,000.00
Salary, Wages
Bonus, Commissions
Dividends, Interest
Other Income
Total Yearly Income

Personal Balance Sheet
Minimum Liquid Assets/Net Worth: $200,000.00/$500,000.00
Assets
Cash
Marketable Securities
Non-Readily Marketable Securities
Net Cash Surrender Value of Life Insurance
Primary Residence Real Estate
Real Estate Investments
IRA, Profit Sharing, Other Vested Retirement Accounts
Deferred Income
Total Assets
Liabilities
Secured/Unsecured Notes - Payable to Others
Accounts Payable
Margin Accounts
$ Notes Due: Partnership
Mortgage Debt
Life Insurance Loans
Other Liabilities
Total Liabilities
Total Net Worth (Total Assets minus Total Liabilities)

Access to Capital
Undercover Systems, Inc. reserves the right to request confirmation from parties named below to verify fund availability.
Letter of Credit
Name
Amount
Bank
Name
Amount
Family
Name
Amount
Other
Name
Amount

Dealer Questionnaire
Please answer the following questions
1. Will the Dealer License be your sole source of income?
2. Total unencumbered liquid capital readily available for use in the business?
3. What is the source of this unencumbered liquid capital?
4. How do you anticipate financing the balance of the total initial investment?
5. Have you ever been or are you currently a Dealer of any other business?
a. If so, what type of business and for how long?
6. Do you or your partner/partners have management or marketing experience?
7. If you do not have any management or marketing experience, what experience do you have that qualifies you to be approved as a Dealer?
8. What percentage of your time will be dedicated to this venture?
9. Our goal for each Dealer is to build brand loyalty by positively impacting their local community.
a. How are you presently involved in your community?
b. What community organization(s) do you maintain a leadership role with?
10. What geographic area are you interested in developing?
11. How soon would you be prepared to join our Dealership program?
By clicking send, I hereby certify that the information supplied in this Dealer Evaluation Form and other financial statements made by me are true and correct. I agree to have all information confirmed by one of your representatives and I authorize you to check references and conduct such additional credit checks as deemed necessary. I further understand that submission of this information does not obligate either of the parties to purchase or sell a License.
Comments
This field is for validation purposes and should be left unchanged.

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Dealer Information

Form of Organization

Principals and Management

Yearly Income

Personal Balance Sheet

Assets

Liabilities

Access to Capital

Letter of Credit

Bank

Family

Other

Dealer Questionnaire