Lead Qualification Details

Fields marked with * are mandatory.

Personal Information

Please complete the entire application. If an item does not apply to you, enter "N/A." False or misleading statements on this form are grounds for terminating the application process and /or grounds for terminating the franchise, should you be granted one.

Initial :
*First Name :
*Last Name :
*Email :
Marital Status : SingleMarried
US / Canadian Citizen : YesNo
Present Address :
*City :
*State / Province :
*Zip / Postal Code :
Cell Phone :
*Home Phone :
Home Ownership : OwnRenting
*Country :
Work Phone :
Work Phone Extension :
Your Birth Date :
Do you have Children currently in Kumon? : YesNo
Center your child Attends :
Best Time To Call :
How did you hear about the Kumon Franchise opportunity? :
Do you understand the initial financial requirements needed to establish a Kumon Math and Reading Center are 70000 liquid capital and 150000 net worth? : YesNo

Education

A four year degree is required. Please upload proof of graduation from a four year program :

College / University - Name And Location :
College / University - Course of Study :
College / University - Years Completed :
College / University - Degree or Diploma :
High School - Name And Location :
High School - Course of Study :
High School - Years Completed :
High School - Degree or Diploma :
Other - Name And Location :
Other - Course of Study :
Other - Years Completed :
Other - Degree or Diploma :

College / University - Upload Document :
High School - Upload Document :
Other - Upload Document :

Employment History

Start with present or most recent employer. An updated resume must accompany this application

Company Name And Address :
Description of Duties :
Date Employed From :
Date Employed To :
Telephone Number :
Supervisor's Name :
Reason For Leaving :
Company Name And Address 2 :
Description of Duties 2 :
Date Employed From 2 :
Date Employed To 2 :
Telephone Number 2 :
Supervisor's Name 2 :
Reason For Leaving 2 :

Specific Data

When would you be ready to invest in your franchise if you were approved? From :
To :
What skills/experience do you have that will help you be successful in this business ? :
Why do you think this franchise will enable you to reach your personal goals? :
How many hours per week will you devote to this business? :
Amount of cash available for investment? :
Have you been approved for financing? : YesNo
Amount Approved ($) :
Would this business be your sole income source? : YesNo
Do you have any contingent liabilities for guarantees, endorsements, leases etc ? : YesNo
Are you now, or have you ever been party to any lawsuit - either as defendant or plaintiff ? : YesNo
Have you ever been convicted of any offense (including misdemeanors for which you have been fined $ 200 or more) ? : YesNo
Have you ever been convicted of a felony? : YesNo
If so, explain :
Have you ever filed for bankruptcy? : YesNo
Date Filed :
Date Discharged :

Area / Location Preferences

Preference 1 :
Preference 2 :
Preference 3 :

Please list the three main questions you have about this business opportunity

Question1 :
Question2 :
Question3 :

Kumon Authorization and Release

As part of the application and approval process I understand that certain background investigations may be conducted. I hereby authorize Kumon North America, Inc. or Kumon Canada Inc. as appropriate (the "Company") or its agent or contractor to procure a Consumer Report which could include obtaining and/or verifying information regarding credit worthiness, credit standing, and credit capacity. This report may be compiled with information obtained from credit bureaus, court record repositories, past or present employers.<br><br>I authorize law enforcement and other government agencies to release to the Company, or its agent or contractor, any existing personal information regarding myself relative to the conviction of any criminal act.<br><br>I authorize all appropriate parties to release, or verify any information.

Initial :
First Name :
Middle Name :
Last Name :
Previous Name: (maiden, a.k.a.) :
Present Address :
City :
State / Province :
Zip / Postal Code :
Country :
Home Phone :
Cell Phone :
Work Phone :
Work Phone Extension :
Social Security Number :
Date of Birth :
Driver's License Number and Province :
Please list cities, states and countries of residence, work and education for the last seven (7) years: :
Signature :
Date :

Note

Kumon will not release personal information you provide us to third parties without your written consent, absent court order or legal process.<br>This application form is not intended as an offer to sell or the solicitation of an offer to buy a franchise. We offer franchises solely by means of our Franchise Disclosure Document.

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