Hydro Physics - Video Pipeline Inspection

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The security and protection of your personal information is extremely important to us. For your protection this area is secured for Internet transmission through Verisign_®.

We ask for your email address only so that we can contact you regarding your completed profile. It will never be sold or given away.

Franchise Information

Candidate Profile

Please complete this summary for a confidential evaluation of your qualifications to become a Hydro Physics_® Franchise. This is not an application and does not obligate you in any way. Please complete as much of the form as possible. The more information about you we have, the faster we can expedite the approval process. Small red stars (*) indicate required fields.

January 18, 2019

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Personal Information

Full Name *
Email Address *
Spouse's Name
Address *
Address 2
City *
State/Province *	Select… Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Canada ------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Zip (Postal Code) *
Years There	1 2 3 4 5 6 7 8 9 10+
Own or Rent?	Own   Rent
Birth Date	Month: 1 2 3 4 5 6 7 8 9 10 11 12    Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year: 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Home Phone *	(000-000-0000)
Work Phone	(000-000-0000)
Best time to call
Is it OK to call during business hours? *   Yes   No
Social Security #	xxx-xx-xxxx
Number of Children or Dependents	0 1 2 3 4 5 6 7 8 9 10+
Character References (excluding relatives) Please enter their name, address, phone number and years known. We would like three references. If you can only provide one or two references, please put "n/a" in the empty reference box(s).
Reference 1
Reference 2
Reference 3

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Education

Level Completed

Self:   Select… High School Trade School Some College 2-Year College Degree 4-Year College Degree Graduate School Other    Spouse:   Select… High School Trade School Some College 2-Year College Degree 4-Year College Degree Graduate School Other

Field of Study

Self:     Spouse:

Degree(s) Earned

Self:     Spouse:

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Experience

Have you ever owned/operated your own business? *   Yes   No If 'Yes', please complete the following:
Firm
Firm Phone
Firm Address
Type of Business
Annual Sales
Your Title
Years in Business	1 2 3 4 5 6 7 8 9 10+
Number of Employees	1 2-10 11-25 26-50 51-100 101+
Current Employment (Self):
Firm
Address
Position/Title
Employed	From  to
Salary
Duties
Current Employment (Spouse):
Firm
Address
Position/Title
Employed	From  to
Salary
Duties
Previous Experience Please complete at least one.
1. *	Business Name/Address
	From  to
	Position/Title
	Annual Income
2.	Business Name/Address
	From  to
	Position/Title
	Annual Income
3.	Business Name/Address
	From  to
	Position/Title
	Annual Income

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Financial

Current Financial Status Please enter numbers only. No commas, periods or dollar signs.
Assets Cash   $  Savings/Certificates   $  Insurance   $  Home Market Value   $  Other Real Estate   $  Stocks/Bonds   $  Automobile(s)   $  Business   $  Other Assets   $  Total Assets   $ 0.00	Liabilities Notes Payable   $  Mortgage   $  Current Obligations Auto Loan(s) Balance   $  Other Liabilities   $  Total Liabilities   $  0.00
Net Worth (Assets less Liabilities)  $  0.00
Do you have cash available for investment? *   Yes   No If 'Yes', please indicate amount:   Select… $0-25,000 $25,000-50,000 $50,000-75,000 $75,000-100,000 $100,000-$150,000 $150,000+
If needed, are additional funds available? *   Yes   No Source:
Do you plan to have a partner? *   Yes   No If so, will the partner be active?   Yes   No
Do you plan to have investors? *   Yes   No If so, to what extent?

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Availability

Do you plan to be the operator of your franchise? *   Yes   No
If so, describe the level of your involvement.
What interests you about Hydro Physics?
How did you learn about Hydro Physics?
Geographical Area(s) Preferred Indicate at least one.
Area 1 *
Area 2
Area 3
When would you want to open your franchise?	Select… ASAP 1-3 months 4-6 months 7-9 months 10-12 months
Comments and Questions
The purpose of this confidential profile is for general information. It is understood, however, that the Company relies on these facts in addressing the qualifications of the Candidate. This is not a contract and thereby does not incur an obligation upon either party. I hereby acknowledge that all the above information is accurate and I authorize Hydro Physics to investigate any and all of the above information.
By entering your name here, you are digitally signing this form.
Candidate Signature *

Hydro Physics_® Pipe Inspection, Corp.
1855 W. Union Avenue, Unit N
Englewood, CO 80110

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