Non-Binding Profile/Application Fields marked with an asterisk (*) are REQUIRED First Name Middle Name Last Name Current Occupation Spouse First Name Spouse Last Name Spouse Occupation Contact Info Mailing Address City State Zip Code Best Contact Phone Number Cellphone Number Email History and Background For Primary Person Have you ever owned a business? Yes No If Yes, what type of business? Your role in previous business? Level of education High school graduate, diploma or the equivalent, GED Some college credit, no degreeTrade/technical/vocational trainingAssociate degreeBachelor’s degreeMaster’s degreeProfessional degreeDoctorate degree Choose Level of Education... Please list any degrees and/or designations you have earned: Please explain other business options you are considering: How do you rate your people skills (10 being the highest) How do you rate your time management skills (10 being the highest) Why do you want to own a business? Please share with us a little about the past years of your life. (school, family, business history, etc.) If you are selected by Nano Concepts how soon can you start? Financial Information How much Capital do you have available? * Home Equity Other Sources Total $ Background Screening Information Driver's License Number Driver's License State of Issuance Optional Information Feel free to share any information with us that you feel may be beneficial to you and Nano Concepts when we consider you for the Nano Shield Business Opportunity. Signatures Please type your full legal name (electronic signature) Your spouse/partner's name (if applicable) By clicking the send button below you are in no way obligated to purchase a Nano-Shield Antimicrobial System business opportunity. I understand that if I elect to go forward with the purchase of a Nano-Shield Antimicrobial System business opportunity I am authorizing Applied Nano Concepts, LLC to perform a criminal background check as a condition of accepting me as a Nano-Shield Antimicrobial System Operator. I understand that the criminal background check will be based on the information provided herein as well as my social security number which will be requested and provided over the phone to safeguard personal identity data. SEND
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