Name:

Email Address:

Address:

City:

Province: British Columbia Alberta Saskatchewan Manitoba Ontario Quebec Nova Scotia New Brunswick Prince Edward Island Newfoundland Northwest Territories Yukon Nunavut

Postal code:

Phone:

Cell:

Spouse's name:

Spouse's Occupation:

Current occupation:

How long at this career?

Have you ever been in business for yourself? Yes No

If you are currently self employed - explain:

Current Annual Income: $20 - $40K $41 - $60K $61 - $80K $81K +

Financial Info

If you go into business for yourself, what amount could you invest? $

Your own capital:$

Borrowed:$

Immediately Available:$

Do you own your own home?: Yes No

Approximately how much equity in your home?

Do you have a line of credit, and if so, how much available?

Which program would you like to start with: Silver Gold Platinum

How many MAX Healthy Vending machines would you like on location after the first year of business?

How much annual income would you like to earn?

If approved as a MAX Healthy Distributor, how soon could you start?

Is there any doubt in your mind that you are capable of handling a business of this kind?: Yes No

Will you be able to devote the time that is needed to supervise this business?: Yes No

Do you understand that the success of your business depends on the efficiency which you handle
your client's need at your locations?: Yes No

Name and addresses of 2 character references (not related to you):

Please tell us why you would like to become a MAX distributor: