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Name: Address:  Street  City  State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY  Zip  Phone:  Email:  Date of birth: (MM/DD/YYYY)  Marital status: married single  Educational background: high school college post grad  What specific geographical location are you interested in?  I can comfortably capitalize a new business at: under 50,000 50,000-75,000 100,000-125,000 150,000-200,000 200,000-500,000 500,000+  Have you ever been self-employed? yes no  What is your current profession? employed from   to    What was your last profession? employed from   to    Have you ever failed in business or filed bankruptcy? yes no  If yes, please explain:  Are there any lawsuits pending against you? yes no  If yes, please explain: From a business perspective, what are your greatest:  strengths  weaknesses  Please let us know your hobbies and special interests: