Gauteng

Western Cape

Free State

Bloemfontein

Limpopo

Hoedspruit

Electrical l Services
	Emergeny 24HR Electrical Services
	COC's - Certificate's of Compliance
	Lighting Design & Maintenance.
	Security & Landscape Lighting
	Surge Protectors.
	Garge door automation
	Gate Motors
	Geysers / Electric Water Heaters
	Electric Fencing
	Power failures
	Wiring
	Stoves
	Pool Pumps & Lights

Questionnaire


Please select your preference:	I am interested in a The Drain Surgeon Plumbing Franchise I am interested in a The Electro Surgeon Franchise (Must be a qualified electrician). I am prepared to look at either option
Personal Information
Name
Surname:
ID Number:
Date of birth:
Age:
Height:
Nationality:
Residential address:
Postal address:
Postal code:
Residence:
Related:
Gender
Home tel:
Work tel:
Cell:
Email
Weight:
Weight:
Marital Status
Postal Code:
Referred to us by:
Former employers List the most recent
Employer 1:
Date from:
Date to:
Address:
Salary received:
Position held:
Reason for leaving:
Position held:
Employer 2:
Date from:
Date to:
Address:
Salary received:
Position held:
Reason for leaving:
References [Names of three people (unrelated) whom you have known for at least one year]
Name:
Phone #:
Name:
Phone #:
Name:
Phone #:
May we contact them?:
If no, the reason:
Spouse Information
If married, does your spouse work?:
Spouse’s annual income R:
Would spouse join the business?:
Position held:
Educational Information
Level obtained:
Qualification:
Date graduated:
Institution:
Number of years:
General Information
Do you have a budget?:
Do you have an organised method of saving or investing?:
List the options below in order of importance
1.
2.
3.
4.
Questionnaire In order for both an individual and a company to grow, they must have common goals and beliefs. The following questionnaire will help determine your needs and ascertain whether or not they run parallel to our needs as an organisation. For your own benefit, please be frank with your answers – you cannot build a successful business on imaginary foundations.
Briefly outline your present duties within your job or business:
If you could have any job or position you wanted, what would you really want to do?
What qualities do you have that you think would be valuable if you became part of The Drain Surgeon/Electro Surgeon?
List the amount of hours spent on the following activities:
Your occupation :
Sleeping:
Playing & relaxing:
Acquiring useful knowledge:
Waste:
Self-improvement:
Family:
Other:
If you could live life again, what changes would you make?
What do you think is likely to make a difference between success and failure in any business?
What do you think has been your greatest accomplishment to date in life?
What has been your greatest disappointment?
What have you done in the past year to improve yourself?
How do you visualise your franchise of The Drain Surgeon/Electro Surgeon?
How much money would you need to earn as a franchisee of The Drain Surgeon/Electro Surgeon considering your minimum financial requirements especially regarding the 1st year?
How does your spouse feel about your interest in becoming a franchisee of The Drain Surgeon/Electro Surgeon?
What do you consider to be your greatest strengths…
What do you consider to be your greatest strengths…
…and your weaknesses?
Which one of our services interests you the most, and why?
What do people most often criticise you for?
What qualities in other people do you dislike the most?
What factors in your past have contributed most to your own development?
What factors have prevented you from moving ahead more quickly?
What else do you think The Drain Surgeon / Electro Surgeon should know about you to understand you better?
If accepted, when could training be scheduled?
Who Encourages you the most?
Who Cautions you the most?
Who Discourages you the most?
Who do you consider the most successful person you have ever met and why?
Personal Financial Information
Bank Name 1:
Branch:
Contact person:
Phone number:
Type account 1:
Type account 2:
Bank Name 2:
Branch:
Contact person:
Phone number:
Type account 1:
Type account 2:
Personal Balance Sheet A description of the section goes here.
Cash in bank
Savings
Loans granted to others*
Property owned*
Shares in listed companies*
Private motor vehicle(s)
Market value of own business (if applicable)
Value of other assets*
A. Total Assets:

Bank loan(s)*
Bond(s) on property*
HP on motors*
HP other*
HP other*
Other liabilities*
B. Total Liabilities

Your net Worth (equals A minus B)

Please provide details of items marked with a () above:
Cash available for investment (own resources or “soft loan” from family, before borrowings):
State minimum drawings per month during first year:
Are you willing to relocate:
If you answered “yes”, please state preferred area(s):
Additional comments you wish to make (optional):
Declaration by applicant: I have completed the above questionnaire to my best knowledge and ability with the intention to be considered for a franchisee of The Drain Surgeon/Electro Surgeon. I understand that at this point I am not binding myself in any way whatsoever. I further understand that, should I be accepted as a franchisee based on the information provided to me, and should it become known to The Drain Surgeon at a later date that the information that has been provided is false, or that I have withheld important facts, this may cause termination of any agreement entered into The Drain Surgeon Franchising Africa (Pty) Ltd and/or The Electro Surgeon (Pty) Ltd and myself.
Understanding *	I understand that by submiting this form I agree to the above declaration.

Name
Surname
Email
Cell
Problem

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The Electro Surgeon Franchising Africa (Pty) Ltd is a full member of The Franchise Association of S outh Africa (FASA) and operates its franchise opportunity in accordance with FASA Code of Ethics and Business Practices.