Prospective Licensee Application

This form, when completed, is an essential part of evaluating your qualifications to be awarded a Kar Koncept Licence. Please print and answer all questions completely. Incomplete applications will not be considered. All answers are held in confidence. The completion of this form does not obligate Kar Koncepts or you in any way.

Email the application to lexusguy74@aol.com OR by snail mail to

Kar Koncepts
Attn Keith Fernandes
53 Doyle Ave,
Providence,
RI 02906

Date: ______________

First Name: ______________________________ Middle:________ Last:______________________________
Current Address: __________________________City:___________ State:____________Zip:______________ 
E-mail: __________________________________
Mobile Phone: ______________________________
Home Phone: ________________________ 
Day Phone: ________________________Fax:________________
Spouse Name:________________________
U.S. Citizen: . Yes . No

Previous addresses for last 5 years
Street/PO Box: ________________________________ City: ____________________ State: ______________
County: ______________________________________ Zip: ____________________ Dates: ____________
Street/ PO Box: ________________________________ City: ____________________ State: ______________
County: ______________________________________ Zip: ____________________ Dates: ____________
Street/ PO Box: ________________________________ City: ____________________ State: ______________
County: ______________________________________ Zip: ____________________ Dates: ____________
Educational History
High School: ____________________________________ 
City, State: ________________________________
Year Graduated:____________________________
College: ________________________________________ 
City, State: ________________________________
Major/Degree:______________________ 
Year Graduated: __________________________
College: ________________________________________ 
City, State: ________________________________
Major/Degree:______________________ 
Year Graduated: __________________________
Grad School:______________________________________ 
City, State: ________________________________
Degree: ____________________________ 
Year Graduated: __________________________
Business Experience
Work history and/or business started. Please give present position first, as well as the positions held prior to that.
Company: ______________________________________ 
City, State: ________________________________
Position: ________________________________________ 
Current Salary: ____________________________
Employed From: __________________________________
To: ______________________________________
Name of Immediate Supervisor: ____________________________________ 
Phone: __________________
Company: ______________________________________ 
City, State: ________________________________
Position: __________________________________ 
Employed From: ________________To: ______________
Name of Immediate Supervisor: ____________________________________ 
Phone: __________________
Company: ______________________________________
City, State: ________________________________
Position: __________________________________ 
Employed From: ________________To: ______________
Name of Immediate Supervisor: ____________________________________ 
Phone: __________________
Have you ever owned or been a partner in a business? . Yes . No
If yes, what type? ________________________________________________________________________
MG
Have you ever been convicted of a crime or convicted in a military court martial? . 
Yes . No
Have you ever been sanctioned or had your licenses suspended or revoked? . 
Yes . No
Are you currently under investigation or subject to pending charges? . 
Yes . No
May we contact your current employer? . 
Yes . No
Have you ever filed for bankruptcy? 
Yes   No

What in you opinion is your credit rating : Excellent / Good/ Average/ Poor

Do you plan to personally operate the business, devoting full time to this venture? .
Yes . No
If yes, what date will you be available to devote your efforts to Kar Koncepts®? ____________

Do you plan to have equity partners? . Yes . No If yes, please identify all proposed equity partners.

(Complete a separate application for each person listed.)
Name/ Address/ Telephone/ Active in business?
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
_____________________________________________________________________
________________________________________________________________________________________________________________________________________________

Capital available for investment: ____________________ 
What is your net worth? __________________

How did you become aware of Kar Koncepts’ license opportunity? ________________________________________________________________________
________________________________________________________________________

Why are you interested in the Kar Koncepts’  opportunity?
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please indicate the areas/locations where you are interested in operating a Kar Koncepts” franchise:
1. ________________________________________________________________________________________________________________________________________________

2. ________________________________________________________________________________________________________________________________________________

3. ________________________________________________________________________________________________________________________________________________

Rate your knowledge of automobiles: Excellent – I can change an engine
                                                             Good – I can change smaller parts
                                                             Average – I can tell you where the parts are in a car
                                                             Basic - I know the number to AAA

Held any Customer Service jobs? Please explain ________________________________________________________________________

________________________________________________________________________

AUTHORIZATION AND RELEASE TO OBTAIN A CONSUMER REPORT
AND/OR AN INVESTIGATIVE CONSUMER REPORT
I, the undersigned consumer, do hereby authorize Kar Koncepts, Inc., by and through to its independent contractor, to procure a consumer report and/or investigate a consumer report on me.
The above-mentioned reports may include, but are not limited to, information as to my character, general reputation,
personal characteristics and mode of living, discerned through employment and education verifications; personal references;
personal interviews; my personal credit history based on reports from any credit bureau; my driving history,
including any traffic citations; a social security number verification; present and former addresses; criminal and civic history/records; any other public record.
I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request to Kar Koncepts, if such is made within a reasonable time after
the date hereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. 1681 et.seq.
I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to Kar Koncepts., by and though our independent contractor, including, but not limited to, any and all courts, public agencies, law enforcement agencies and credit bureaus, regardless of whether such a person, business entity or governmental agency compiled the information itself or received it from other sources.
I hereby release Kar Koncepts, and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims and/or demands, by me, my heirs, or others making such a claim on my behalf, for providing a consumer report and/or investigative consumer report hereby authorized. I
understand that this Authorization/Release form shall remain in effect for the duration of my Franchise relationship with said Company.
Further, I certify that the information contained on this Authorization/Release form is true and correct.

Signature: ________________________________________________

Printed Name: _____________________________________________
Previous Names Used: ________________________________ 
Dates Used: __________________________
Social Security No:_____________________
Driver’s License Number: ______________________________
State of Issuance: ____________________
Gender*: __________ Place of Birth*: ____________________________ 
Date of  Birth*: ________________