CONTACT INFORMATION

First Name Last Name

Street Address City

Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Nunavut Northwest Territory Yukon Territory Postal Code

Email Address Home Phone

Work Phone Cell Phone

EMPLOYMENT & BUSINESS EXPERIENCE

Present Occupation

Business Address

Street Suite

City Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Nunavut Northwest Territory Yukon Territory Postal Code

Business Experience

1. From 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 To 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 Name Position Annual Income

2. From 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 To 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 Name Position Annual Income

3. From 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 To 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 Name Position Annual Income

Business Reference

1. Name & Title Company

Street Address City Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Nunavut Northwest Territory Yukon Territory Phone

2. Name & Title Company

Street Address City Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Nunavut Northwest Territory Yukon Territory Phone

3. Name & Title Company

Street Address City Province British Columbia Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Nunavut Northwest Territory Yukon Territory Phone

EDUCATION

High School Year Completed 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 Diploma Received Yes No

College or University Year Completed 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 Diploma Received Yes No

Other (please specify)

HEALTH

Doctor's Name Street Address Phone

What is the general state of your health?

Do you have any serious illness or disibility? Yes No If Yes, Please Explain Briefly

CREDIT REFERENCES

Banks

1. Name Street Address Phone

2. Name Street Address Phone

Investment Company or Stock Broker

1. Name Street Address Phone

2. Name Street Address Phone

Credit Cards

1. Name Institution

2. Name Institution

Accounting Firm

1. Name Street Address Phone

Legal Counsel

1. Name Street Address Phone

APPLICANT'S STATEMENT OF NETWORTH

Assets

Cash On Hand Notes & Accounts Owed Real Estate

Cash Surrender Value Of Stocks, Bonds & Investments

Automobiles Miscellaneous TOTAL ASSETS VALUE

My assets are held jointly with my spouse? Yes No

Liabilities

Notes Payable to Banks & Others Notes & Accounts Due to Others

Loans On Life Insurance Policies Real Estate Mortgages

Real Estate Assessments Unpaid Taxes Miscellaneous

TOTAL LIABILITIES

NET WORTH

Do you have any judgements issued against you? Yes No Do you have any litigious proceedings pending or threatened against you? Yes No

Do you have an Unencumbered Cash and Investment amount of $1,000,000.00? Yes No If not, how much?

Do you have a Working Capital amount of $500,000.00? Yes No If not, how much?

Please explain the source of funds for this investment.

What are the specific assets to be used to fund the unencumbered cash amount?

Asset Value

Asset Value

Asset Value

Asset Value

Asset Value

Asset Value

Total Cash to Close

GENERAL INFORMATION

Why are you interested in Gold's Gym Canada?

Are you willing to devote a minimum of 2 weeks to training? Yes No

When can you begin?

Are you willing to devote your full time to this business? Yes No

Do you plan on having a partner? Yes No

Have you seen an existing franchise? Yes No Where?

Which location are you interested in?

1st Choice

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

2nd Choice

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

3rd Choice

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

Would you be willing to relocate? Yes No

Desired Income in First Year? Annually in Five Years?

Thank you for taking the time to fill out this Franchise Application for Gold's Gym Canada.

By clicking on the submit button below you certify that all of the above information is true to the full extent of your knowledge. All information will be held in the strictest confidence by Gold's Gym Canada. Please allow a reasonable amount of time for us to respond.

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