Tell Us About Yourself Franchise Referral Form Primary Contact InformationName* First Last Occupation* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* How did you hear about us?*AmericasBestFranchise.comBizBuySell.comFranchise SolutionsFranchise.comEntrepreneur MagazineFranchise DirectSearch EngineReferralReferred By* Current Franchise Owner Franchise Broker Referred By: First Last Have your previously owned a business?* Yes No Highest Level of Education achieved*GEDHigh School DiplomaSome CollegeAssociates DegreeBachelors DegreeMasters DegreeDoctoral DegreeOther business opportunities you are considering?What appeals to you most about a Live 2 B Healthy® Franchise?*On a scale of 1 - 10 (10 being Most Skilled), how do you rate your people skills*Please enter a number from 1 to 10.On a scale of 1 - 10 (10 being Most Skilled), how do you rate your leadership skills?*Please enter a number from 1 to 10.Are you more of a Salesperson or a Relationship Builder?* Salesperson Relationship Builder What are your reasons for wanting to be in business for yourself?*Do you have someone close to you who will be involved with the business?* Yes No Please tell us a little bit about your last ten years (school, family, business history, affiliations, etc.)*If you are awarded a Live 2 B Healthy® franchise, why would you be a great addition to our team?*If you are awarded a Live 2 B Healthy® franchise, how soon could you start?As soon as possible< 30 Days31-60 DaysMore than 61 daysFinancial InformationCapital available (from cash, savings, checking, money markets, etc.):*Home Equity:*Securities (stocks, bonds, mutual funds, etc.):*IRA's / 401k's:*Other funding sourcesProfessional ReferencesFirst Reference Name* First Last References should not be related to you.Professional relationship: First Reference's Phone Number*Second Reference Name* First Last References should not be related to you.Professional relationship: Second Reference's Phone Number*CommentsPlease share any information that you feel may be beneficial to your application:SignaturesNotice:* Yes, I understand I understand that by signing and submitting this form, I am granting Live 2 B Healthy® permission to contact the references listed above.Primary Applicant* First Last Potential business partner's name (if applicable) First Last CAPTCHA