to the number indicated for your province below:
ON 905-856-2856
QC, NB, NS, PE, NL 514-733-2700
This application form is not intended as an offer to sell or the solicitation of an offer to buy a franchise. We offer franchises solely by means of
our Franchise Disclosure Document. Certain provinces and foreign countries have laws governing the offer and sale of franchises. If you are a
resident of one of these provinces or foreign countries, we will not offer you a franchise unless and until we have complied with all applicable
legal requirements in your jurisdiction.
PROSPECTIVE FRANCHISEE APPLICATION
Kumon Canada Inc.
6240 Highway 7, Suite 300
Woodbridge, ON L4H 4G3
Toll-Free: 1-800-266-6681
www.kumon.ca
www.kumonfranchise.ca
BC, AB, SK, MB, NT, YT, NU 604-454-1002
EDUCATION:
Years
School Name & Location Course of Study Completed Degree or Diploma
College/University
High School
Other
PERSONAL DATA:
Name:
Mr./Mrs./Ms. ______________________________,
________________________________________________________
(circle one) Last First Middle
Address:
Telephone:
____________________________________________________ Home: ( )
____________________
_______________________
__
Postal Code: _______
Work:
(
)
____________________
Email Address:________________________________________________
Are you a Canadian Citizen? Yes No
Yes No
If not, are you eligible to own a business? Yes No
Do you have children?
Their Ages:
If Not a Canadian Citizen, what is your immigrant or non-immigrant status?
(Please provide documentation)
How did you learn of our organization? Check all that apply.
Through a friend Newspaper (which paper?)
__________________________________
Have children in Kumon Radio (which station?)
______________________________________
Teacher Referral Website (which site?)___________
____________________________
Other _________________
SPECIAL SKILLS, ABILITIES, ETC.:
Languages:
What is your native language? __________________________
What other languages do you speak/write? ________________
__________________________________________________
Do they currently attend Kumon?
Yes No
Instructor's Name?
City:
Province:
Fax:
Cell:
( )
____________________
( )
A four year degree is required. Please attach proof of graduation from a four year degree program.
Thank you for inquiring about the Kumon franchise opportunity. Please complete the entire application. Please print or type
If an item does not apply to you, enter “N/A.” Attach additional pages if neccessary. False or misleading statments on this
form are grounds for terminating the application process and /or grounds for terminating the franchise, should you be granted
one. This application form is not an employment contract or franchise agreement. Submitting this form does not obligate you
or Kumon in any way.
This application form should be completed by an individual whose intention is to be a full-time Kumon Instructor. In the
Kumon franchise system, the Instructor who is trained and certified in the Kumon Method must operate the centre.
Kumon will not release personal information you provide us to third parties without your written consent, absent court order
or other legal process.
Prospective Franchisee Application
____________________
Prospective Franchisee’s Name
________________
1
_
_
_
_
_
_
_
Do you currently work or
volunteer at a Kumon Centre?
Yes No
EMPLOYMENT AND BUSINESS HISTORY:
(Start with present or most recent employer. An updated resume must acompany
this application.)
Company Name & Address: Description of Duties:
__________________________________________ From:________________
__________________________________________ To:________________
Telephone Number: ( 000 ) __________________ Reason for leaving:
Supervisor’s Name: ________________________
Company Name & Address: Description of Duties:
_________________________________________
_ From:________________
__________________________________________ To:________________
Telephone Number: ( 000 ) __________________ Reason for leaving:
Supervisor’s Name: ________________________
Do you now or have you ever been licensed to operate a franchise?
Yes No
If yes, describe: __________________________________________________________________________________________
Are any lawsuits pending against you? Yes No
If yes, describe: __________________________________________________________________________________________
Yes No
If yes, describe: __________________________________________________________________________________________
BUSINESS PLAN:
City or Town in which you are interested: ____________________________________________________________________
If that area is not available, are there other areas of interest? Pleaselist: __________________________________________
When will you be able to start this business? ___ / ___ / ___
How many hours per week will you devote to this business? ____________________________________________________
PERSONAL REFERENCES:
Name Address Telephone Number Relationship
(Kumon requires franchisees to dedicate themselves full-time to the operation of the Kumon Franchise. You
Prospective Franchisee’s Name
__________________________________________
2
Dates Employed:
Dates Employed:
Have you ever been arrested?
If
yes, please explain:
______________________________________________________________________________________
Yes No
cannot hold any employment if you are granted a Franchise.)
FINANCIAL STATEMENT: As of ______________, 20 ________.
This is a statement of: My individual financial information The financial information of my spouse and me
Assets Amount Liabilities Amount
Cash in banks $ ____________________ Notes payable to bank $ ______________________
Real estate $ ____________________ Real estates amount owed $ ______________________
Stocks and Bonds $ ____________________ Loans on life insurance policies $ ______________________
Accounts receivable $ ____________________ Other liabilities (describe) $ ______________________
Cash surrender value __
of your life insurance $ ____________________
$ ______________________
Auto 1
(year and make) $ ____________________
$ ______________________
Other assets (describe) $ ____________________ $ ____________________
TOTAL ASSETS $ TOTAL LIABILITIES $
NET WORTH (Total Assets minus Total Liabilities) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Annual Income Amount Annual Expenditures Amount
Salary or wages (own)
$
________________ (net) Property taxes and assessments $ ______________________
Dividends and interest $ ____________________
Federal and provincial income taxes $ ______________________
Rental income
(gross) $ ____________________
Real estate mortgage
payments (per year)
$ ______________________
Business income
(net) $ ____________________ Payments on contracts (Other notes) $ ______________________
Other income
(describe) $ ____________________ Estimated living expenses $ ______________________
$ ____________________ Other $ ______________________
TOTAL INCOME $ TOTAL EXPENDITURES $
Do you currently have a source of financing? Yes No Savings Account: Yes No
How much capital are you able to invest? ____________________ Checking Account: Yes No
Will you use personal assets to finance this franchise? Yes No
Please explain: __________________________________________________________________________________________
Have you filed for bankruptcy or compromised a debt during the past seven years? Yes No
If yes, please explain. Attach additional sheets, if necessary.________________________________________________________
Are your cash deposits held in joint tenancy? Yes No, with whom? __________________________________________
Bank Name: ____________________________________________ Phone: ( 000 ) ________________________________
Address: __________________________________________________ City/Province/Postal Code:______________________
$
(Please check one:)
We require $70k - $150k liquid assets. We will require you to complete a more detailed financial check in which you must provide
proof of the information provided (bank statements, paystub, stocks, tax returns).
Auto 2
(year and make) $ ____________________
Salary or wages (
spouse)
$
________________ (net)
3
Prospective Franchisee’s Name
______________________________
KUMON CANADA INC. AUTHORIZATION AND RELEASE:
As part of the application and approval process I understand that certain background investigations may be conducted. I hereby
authorize Kumon Canada Inc. (the "Company") or its agent or contractor
to procure a Consumer Report which could include
obtaining and/or verifying information regarding credit worthiness, credit standing, credit capacity, general character, general
reputation or personal characteristics. This report may be complied with information obtained from credit bureaus, court record
repositories, department of motor vehicles, past or present employers, educational institutions, governmental occupational
licensing or registration entities, business or
personal references and any other source.
I authorize law enforcement and other government agencies to release to the Company, or its agent or contractor, any existing
personal information regarding myself relative to the conviction of any criminal act.
I authorize all appropriate individuals, companies, institutions, schools, government authorities to release, or verify any information.
I understand that a photocopy of this authorization would be accepted with the same authority as the original.
Name : Mr./Mrs./Ms. ______________________________________________________________________________________
(circle one) Last First Middle
Previous Name: (maiden, a.k.a.) ____________________________________________________________________________
Address: ______________________________________________________ Phone Numbers:
______________________________________________________________ Business: ( 000 ) ______________________
City/Province/Postal Code: _____________________________________ FAX: ())))) ) ______________________
Province: ____________________ Country: ______________________ Residence:. ( 000 ) ______________________
Social Security Number: ________________________________________ Date of Birth: ________/_________/________
Month Day Year
Driver's License Number and Province: ____________________________
Please list cities, provinces and countries of residence, work and education for the last seven (7) years: ________________
Signature: ______________________________________
Date: ______________________________________
Kumon will not release personal information you provide us to third parties without your written consent, absent
court order or legal process.
4
Prospective Franchisee’s Name
______________________________________
REQUIRED COMMENTS:
Please use this space and any additional sheets to tell us anything else you think is relevant, such as family business history,
Signature: ________________________________________________ Date: ____________________________________
Spouse's Signature: ________________________________________ Date: ____________________________________
CERTIFICATION AND WAIVER:
I certify that the information I have provided on this application is complete and correct. I understand that false
or misleading statements on this form are grounds for terminating the application process, and/or grounds for
terminating my franchise, should I be granted one.
Print Name: ________________________________________
Signature: ________________________________________
Date: ________________________________________
FOR OFFICE USE ONLY:
Received By:________________________________________________ Date: ____________________________________
5
Prospective Franchisee’s Name
______________________________________
Franchise.
