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

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

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.