FRANCHISE APPLICATION FORM

(Complete in full and do not use abbreviations. Please print clearly or type)
The filling of this application does not oblige the applicant to become a franchisee of Oldtown White Coffee

Personal Information
Applicant's Name

: ___________________________________________________________________ NRIC No.

Correspondence

: _____________________________________________________________________________________________

Address

_____________________________________________________________________________________________
_____________________________________________________________________________________________

City

: ____________________________________ State

: _____________________________________

Postal Code

: ____________________________________ Country

: _____________________________________

Phone No.

: (H)________________________________________________ (M)_______________________________________

Marital Status

: ______________________________________________________________________________________________

Spouse's Name

: ______________________________________________________________________________________________

Spouse's Occupation

: ______________________________________________________________________________________________

Total No. Dependants

: ______________________________________________________________________________________________
Employment/Business Experience
Please attach a separate sheet if additional space needed

Position

: ______________________________________________________________________________________________

Company

: ______________________________________________________________________________________________

Address

: ______________________________________________________________________________________________

: ______________________________________________________________________________________________

: ______________________________________________________________________________________________
City

: ____________________________________ State

: _____________________________________

Postal Code

: ____________________________________ Country

: _____________________________________

Phone No.

: _________________________

: _____________________________________

Position

: ______________________________________________________________________________________________

Company

: ______________________________________________________________________________________________

Address

: ______________________________________________________________________________________________

Annual Income

: ______________________________________________________________________________________________

: ______________________________________________________________________________________________
City

: ____________________________________ State

: _____________________________________

Postal Code

: ____________________________________ Country

: _____________________________________

Phone No.

: _________________________

: _____________________________________

Annual Income

What is your location perference?

State

: _________________________

City

: ________________

Do you plan to have equity partners?

YES

Location
NO

If YES, complete the following;

Name of Partner

: ______________________________________________________________________________________________

Relationship

: ______________________________________________________________________________________________

Address

: ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

City

: ____________________________________

State

: _____________________________________

Postal Code

: ____________________________________

Country

: _____________________________________

Phone No.

: (H)_________________________________________________ (M)______________________________________

Name of Partner

: ______________________________________________________________________________________________

Relationship

: ______________________________________________________________________________________________

Address

: ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________
City

: ____________________________________

State

: _____________________________________

Postal Code

: ____________________________________

Country

: _____________________________________

Phone No.

: (H)_________________________________________________ (M)______________________________________

Name of Partner

: ______________________________________________________________________________________________

Relationship

: ______________________________________________________________________________________________

Address

: ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________
City

: ____________________________________

State

: _____________________________________

Postal Code

: ____________________________________

Country

: _____________________________________

Phone No.

: (H)_________________________________________________ (M)______________________________________

Name of Partner

: ______________________________________________________________________________________________

Relationship

: ______________________________________________________________________________________________

Address

: ______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________
City

: ____________________________________

State

: _____________________________________

Postal Code

: ____________________________________

Country

: _____________________________________

Phone No.

: (H)_________________________________________________ (M)______________________________________
THE REST OF PAGE IS INTENTIONALLY LEFT BLANK

SCHEDULE A - FINANCIAL (CASH ON HAND AND IN BANK)

* Kindly attached the documents
Name of Bank / Financial Institution

Country

SCHEDULE B - CASH VALUE OF LIFE INSURANCE

* Kindly attached the documents
Name of Insurance Company

Face Amount

SCHEDULE C - REAL ESTATE OWNED

* Kindly attached the documents
Description of Property

Name on Title

Cost

Market Value

References:
List three (3) References you have known at least 5 years (Do not include relatives).

Name

Address

Relationship

List all Business In Which You Have Financial Interest

Name

Address

Position

THE REST OF PAGE IS INTENTIONALLY LEFT BLANK

Personal Financial Statements as of ______________________________

Assets
Cash on Hand & In Bank
Cash Value of Life Insurance

Real Estate Owned

Other

Total Assets

Liabilities
: RM__________________
: RM__________________
: RM__________________
: RM__________________
: RM__________________
: RM__________________
: RM__________________
: RM__________________

: RM__________________

Real Estate Mortgage(s) Payable

Loan Against Cash Value of Life

Insurance

Total Liabilities
Net Worth

I understand that the granting of franchise is at the sole discretion of Oldtown White Coffee.

I understand that I and/or representatives will have to be successfully complete Oldtown White Coffee's training program and competent to operate prior to the start of business opera

I have read this application and everything I have stated in it is true. I understand that Oldtown White Coffee, in granting me a franchise, will rely upon the inf
me.

Authorised Signature (required)

Print Name
Date

: ____________________________
: _________________________________________________________
: ____________________________

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I hereby authorise Oldtown White Coffee, its agent and all credit agencies, educational institutions, corporations, current and former employers, la
government agencies, city state, country and federal courts, military services and persons to release any information they may have about me to the c
this has been field, or their agent.

I release Oldtown White Coffee and/or its agents and any person or entity which provided information pursuant to this information, from any and all
lawsuits in regards to the information obtained from any and all referenced sources used.

_______________________________________

__________________________________

Applicant's Signature

Date

_______________________________________

Print Name
Kindly email the form and the required attachment to ;
Business Development Department,
Kopitiam Asia Pacific Sdn Bhd,
Lot 896, Jalan Subang 10, Taman Perindustrian Subang,
47600 Subang Jaya, Selangor, Malaysia
or at myfranchise@oldtown.com.my

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Amount

Cash Value

Balance Owed Mortgage Holder

Relationship

Contact No.

Year Started

Shareholding
Percentage (%)

10

es
: RM___________________________
: RM___________________________
: RM___________________________
: RM___________________________
: RM___________________________
: RM___________________________
: RM___________________________

the start of business operations.

e, will rely upon the information provided by

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d former employers, law enforcement and

have about me to the company with which

tion, from any and all liabilities, claims or

_____________________
Date

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