New Investor Questionnaire

Please provide the following information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please provide your Employment Experience in the space below. Please list company name, position held and dates of employment. If you own a business, please provide that information in the next box.

Have you ever owned a business? If yes, please explain the type of business:

Enter your Total Assets ($) in the space provided below:  

Enter your Total Liabilities ($) in the space provided below:

Enter your Net Worth ($) in the space provided below:

Enter your Cash Available ($) in the space provided below:

Have you ever filed for bankruptcy or been a principal in a corporation that has filed for bankruptcy?

Yes No

Please provide any additional information you would like to provide to us:

What geographical area(s) are you interested in owning or purchasing a coin laundry business? (Use the Ctl key to make multiple selections)

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Canada Caribbean Mexico

Please provide today's date:

-- mm/dd/yy