EmailMe Form - Elemen Partnership Application Form

For which Country? *

For which City / State / Province? *

1) Contact Information

a) Name of Main Applicant *

Prefix First Last

This should be the main contact person for this application, and wholly involved in the business.

b) Gender *

Male

Female

c) Date of Birth *

DD / MM / YYYY

d) Contact Number
Please include Country Code (+) *

This is the number that we will use to contact you in relation to this application

e) Email *

This is the email address that we will use to correspond with you in relation to this application

Confirm

f) Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

2) Career Background & Work Experience

a) Current Employment Status *

Employee

Self-Employed

Unemployed / Retired

b) Name of CURRENT Company

b1) Position / Title

b2) Years in Company

c) Name of PREVIOUS Company

c1) Position / Title

c2) Years in Company

d) Do you have ownership in any food and beverage establishments previously (or currently)? *

Yes

No

d1) If YES for above, please elaborate:

e) Have you worked in any food and beverage establishments previously (or currently)? *

Yes

No

e1) If YES for above, please elaborate:

3) Financial Background and Information

Please use United States Dollar (USD)

a) Income from current occupation *

Please indicate on a per annum basis

b) Income from other sources

Please indicate on a per annum basis

b1) What are your other sources of income?

c) Individual Liquid Assets *

(Cash, Stocks, etc.)

d) Individual Fixed Assets *

(Property, Car, etc.)

e) Individual Liabilities *

(Mortgages, Loans etc.)

4) Business Information

a) Will this Business be your sole source of income? *

Yes

No

b) How will you finance this business? *

100% Self Finance

Business Loans

Joint Venture Partnership

c) If this application is successful, how soon will you wish to start this business? *

0 - 6 months

6 - 12 months

more than 12 months

d) How much will the Main Applicant be involved in the operations of this business? *

Fully

Partially

Just an Investor

e) What is the % of equity you will own of this business? *

51% - 100%

25% - 50%

less than 25%

On what basis do you see a good potential for Elemen in your market *

5) Additional Information

a) Have you been convicted in a criminal court of law in any country? *

Yes

No

a1) If Yes, please elaborate

b) Are you an undischarged bankrupt? *

Yes

No

c) Have you been associated directly or indirectly with any terrorists activities? *

Yes

No

d) Are you involved in in any litigation proceedings currently in any court of law in any country? *

Yes

No

6) Character and/or Business References

Please provide two referees. Do not include spouse or relatives.

You understand and agree that any inquiry regarding your character, personal characteristics and financial background maybe conducted as a result of information required by R&B Tea Pte Ltd

a) Referee 1: Name *

Prefix First Last

Relationship *

Email *

Phone *

Please include Country Code (+)

b) Referee 2: Name *

Prefix First Last

Relationship *

Email *

Phone *

Please include Country Code (+)

Declaration

I hereby declare that all information given and questions answered in this application form are true and correct to the best of my knowledge and I understand that any misrepresentation or concealment of material information on my part will be sufficient reason for the dismissal of this application without any liability to the company. *

I agree

I disagree