Licensee Interest Survey

Personal Information
* First Name		* Last Name
Address		Line 2
City		State	Zip
* Phone Number		* Email Address
Children (& ages)		Marital Status	Married Single

Further Education
College / University		Graduate University
Dates Attended		Dates Attended
Major		Major

General Questions

Briefly explain the main reason(s) for your interest in entering into a U.K. Petite License agreement

Briefly describe your qualifications to enter into a U.K. Petite License agreement

Have you ever had an interest in a similar operation (if yes please explain)

Would you be responsible for the day to day operation of the business? If not who will?

Who would teach the U.K. Petite Camps and Programs?

Other / Legal
Have you ever declared bankruptcy?	Yes No
Please explain
Do you have any criminal convictions?	Yes No
Please explain
Have you ever been accused of or involved in an incident involving the sexual or physical abuse of a child?	Yes No
Please explain
Have you ever had any serious or permanent debilitating illness?	Yes No
Please explain
Are you currently undergoing any medical treatment?	Yes No
Please explain
Do you currently take any prescription medication?	Yes No
Please explain