The B-12 Store Licensing Agreement Application
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Female
Male
Prefer not to say
Other
Address
*
City
*
State
*
Zip Code
*
Phone Number
*
Occupation
*
Email Address
*
Financial Background
Have you ever owned your own business?
*
Yes
No
If yes, what is the name of your business?
Are you currently employed?
*
Yes
No
If yes, where?
Have you ever filed bankruptcy?
*
Yes
No
Do you have $25,000 or more in savings?
*
Yes
No
Do you have $50,000 or more in savings?
*
Yes
No
Licensee Details
Would you be the sole licensee?
*
Yes
No
If no, please list the others' names
What state do you wish to open in?
*
Do you plan on opening in a mall?
*
Yes
No
Other
If no, then where?
Submit
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