| Name: |
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| Address: |
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| Telephone Number: |
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| Email Address: |
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Do you speak English?
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YesNo |
| If not, please provide your language preference: |
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Would you like for us to contact you?
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YesNo |
| What company did you purchase a franchise from?: |
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Were you provided with a Uniform Franchise Offering Circular/Franchise Disclosure Document?
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YesNo
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| If so, the effective date of the UFOC/FDD: |
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Did you receive the UFOC/FDD ten or more days prior to purchasing the franchise?
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YesNo |
| Date Franchise Agreement Signed: |
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| Date Started: |
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| Date Terminated (if applicable): |
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Did you sign a release when you ceased doing business?
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YesNo |
| Please state how much money you believe you have lost/gained as a result of this franchise. Please be as specific as possible.: |
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| Please state your opinion as to why this franchise failed or is succeeding.: |
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| Please state what you believe the franchisor did or did not do to contribute to your loss/gain.: |
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| Please provide a brief narrative concerning your experiences.: |
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