Checkers Drive-In Application Form

DA # _________________

Franchisee Application Form

Personal Profile

Number of

Name: __________________________________

Date: __________________________________

Proposed Restaurants: ___________________

Preferred Area: #2__________________________

Preferred Area: #3__________________________

Preferred Area #1:__________________________

Application Ch ecklist

Please use this checklist to insure your Application can

be processed. All items listed belo w should be returned

to Checkers for processing.

Franchise Application Form & Personal Profile

Background Release Form

Background

Release

Form

Substantiating Financial Information Listed on the

‘Financial Information Submission’ Sheet (Must substantiate Minimum

Requirement for Liquid Cash of $250K) Please supply all financial

backup documentation.

Franchise Disclosure Document (FDD) - Item 23

(FDD must be acknowled ge d as received before any f orm al document s can be signed)

Name: Spouse:

Address:

City: State: ________ Zip:

_____________________

Company:

Address:

Dates: Salary: __________________________

Company:

Address:

Dates: Salary: __________________________

Company:

Address:

Dates: Salary: __________________________

Company:

Address:

Dates: Salary: __________________________From: __________ To: ___________

________________

_________________________________________________________________________________

Position Held: __________________________ Supervisor: __________________________

From: __________ To: ___________

___________________________________ Type of Business: __________________________

_________________________________________________________________________________

Position Held: __________________________ Supervisor: __________________________

From: __________ To: ___________

___________________________________ Type of Business: __________________________

_________________________________________________________________________________

Position Held: __________________________ Supervisor: __________________________

From: __________ To: ___________

___________________________________ Type of Business: __________________________

_________________________________________________________________________________

Position Held: __________________________ Supervisor: __________________________

Business Background - minimum of 10 years

___________________________________ Type of Business: __________________________

subsidiary or company affiliated with any of the above? Yes _____ No ______

If yes, please list employer, duties and/or name of relative: ____________________________________________

____________________________________________________________________________________________

How did you learn about Checkers/Rally's? ________________________________________________________

Driver's License Number: __________________________

Are you, or any member of your family, or any proposed partner in this venture, currently or have you ever been

employed by Checkers/Rally's, or related to any franchisee, supplier or vendor or Checkers/Rally's or any

Date of Birth:

Cell Phone: _________________ Social Security Number _____________________

May we contact you here? Yes _____ No ______

Business Phone: _________________ May we contact you here? Yes _____ No ______

__________________________

Home Phone: _________________

Date Submitted: _________________

__________________________ __________________________

e-mail address: ______________________________

PERSONAL PROFILE

CONFIDENTIAL

**This application does not obligate either party in any manner

Please complete the following for each applicant signing the Franchise Agreement**:

Yes ____ No _____

Have you ever owned a franchised food operation?: Yes ____ No _____

Last name: Middle: ________

Occupation: ________

Phone:

Last name: Middle: ________

Occupation: ________

Phone:

Last name: Middle: ________

Occupation: ________

Phone:

Last name: Middle: ________

Occupation: ________

Phone: _________________

Will your partner devote full time to this business: Yes _____ No _____

_________________ First name: _________________

_________________ Percent of Ownership:

_________________

Will your partner devote full time to this business: Yes _____ No _____

_________________ Will your partner devote full time to this business: Yes _____ No _____

_________________ First name: _________________

_________________

First name: _________________

_________________ Percent of Ownership:

_________________

Will your partner devote full time to this business: Yes _____ No _____

Partners or any associates who will join you in this venture must also complete one of these forms. Partners or

equity contributors who will be signing the Franchise Agreements or Development Agreements must also

sign a Franchise Disclosure Document - Item 23 Receipt.

_________________ First name: _________________

_

_________________________________________________________________________________________

_

Proposed Partners

If no, indicate how you will divide your time:__________________________________________________________________

_

_________________________________________________________________________________________

_

Will members of your family be directly involved with the day-to-day operations of this business? Yes _____ No _____

If yes, please identify who, their capacity and previous work experience: ____________________________________

_

_________________________________________________________________________________________

_

_________________________________________________________________________________________

_

Will you be able to devote full time to this business? Yes _______ No ________

_

_________________________________________________________________________________________

_

_________________________________________________________________________________________

_

Are you a party, either as a plaintiff or as a defendant, to any lawsuits, litigation or legal actions?: Yes _____ No _____

If yes, please describe:__________________________________________________________________________________

_

proceedings or compromise with creditors? Yes _______ No _______

If yes, please provide complete details: ____________________________________________________________

_

_________________________________________________________________________________________

_

Please describe if you have, if any, constraints through an arrangement or contract that would interfere in becoming

a franchisee of Checkers/Rally's? _______________________________________________________________

_

_________________________________________________________________________________________

_

______________________________________________________________

_

If yes, name the franchise and the manner in which you left the system:

_

___________________________________

_

_________________________________________________________________________________________

_

Have you, or any business entity in which you have owned an interest, been involved in bankruptcy, insolvency

Questionnaire

Do you currently own a franchised food operation?:

If Yes, name the franchisor:

_

______________________________________________________________

_

Location of the food operation:

_

______________________________________________________________

_

Are you planning on financing with a lending institution? Yes ____ No _____

If yes, please specify

Source of Liquidity :

Yes ____ No _____

DATE:

detailed breakdown of your assets and liabilities.

SIGNATURE: ___________________________________

_

________________

_

Either using a separate schedule or the attached Supplementary Schedules you will need to provide a more

_

__________________________________________________________________________________________

_

List any other commitments or contingent financial liabilities not listed above including leases:

_

__________________________________________________________________________________________

_

__________________________________________________________________________________________

_

_______________________________________________________________________

_

General Information

Are you a co-signor, guarantor or endorser to any obligations?

If yes, please provide relationship and amount(s):

_

____________________________________________

_

Commission: ________________

Other Income:

_

_______________________________________________________________________

_

Bonus: ________________ Interest & Dividends ________________

Annual Income

Salary: ________________ Spouse's Salary ________________

TOTAL LIABILITIES: _________________

TOTAL NET WORTH _________________

Retirement accounts: _________________

TOTAL ASSETS _________________

Personal possesions: _________________

Other assets: _________________

Other real estate (M/V): _________________

Accounts, Notes Receivables (list

separate page):

_________________

Real estate, your residence: _________________ Other Liabilities _________________

Public stocks, bonds securities: _________________ Accounts, Notes & Loans Payable _________________

Stock in your business: _________________ Mortgages Payable _________________

Financial Information

Assets Liabilities

Cash on Hand and Unrestricted:

(Total Liquid Cash Minimum $250,000) _________________ Notes Payable _________________

Location

Mortgages

Liens

Amount

Estimated Cash Value

__________________________________________________________________________________________

Type of Property

Original Cost Market Value Monthly Payments

Nature of Transaction Receivables Due Payables Due

Description

5. Other Assets/Liabilities

__________________________________________________________________________________________

Amount of Liability

__________________________________________________________________________________________

4. Accounts, Notes and Loans

(Payables and Receivables - indentify which)

__________________________________________________________________________________________

3. Real Estate

__________________________________________________________________________________________

2. Publicly Traded Stocks, Bonds & Securities

Number of shares of stock and Face

Value of Bonds

(List Separately) Present Market ValueDescription

__________________________________________________________________________________________

Supplementary Schedules

1. Banking Activity

Bank Name City/State Cash Assets Loan Liabilities Monthly Payments

CPA NAME

CPA ADDRESS

CPA PHONE NUMBER

CPA FAX NUMBER

Today’s Date

To whom it may concern:

I/We are the accountants for Candidate1 and have been for XX years.

The purpose of this memo is to verify that as of this date, Candidate1 owns liquid assets

of at least $XX and has a total net worth of at least $XX.

Please call me if you have any questions.

Sincerely,

CPA Signature

CPA Name

CHECKERS

March 2012

EAST\42859613.1

EXHIBIT A

FRANCHISE APPLICATION

CHECKERS

March 2012

EAST\42859613.1

CHECKERS DRIVE-IN RESTAURANTS, INC.

APPLICATION FOR FRANCHISE

The undersigned (“Applicant”) hereby applies for a franchise for the operation of a

Checkers Drive-In Restaurant to be located at the following location:

(the “Preferred Site”).

Concurrently, Applicant shall pay Checkers Drive-In Restaurants, Inc., (“the

Company”) an application processing fee of $1,000. The application fee is a fully earned

payment and non-refundable. Applicant acknowledges and agrees that the Company has

granted no rights whatsoever to the Applicant with respect to the Preferred Site, except as

specifically set forth herein.

The Company agrees that for the period during which the application is being

reviewed (beginning on the date hereof and continuing through the date Checkers notifies

Applicant that the application has been approved or denied), the Company will not enter into

an agreement with any other franchisee to develop a Checkers Restaurant on the Preferred

Site. Applicant may simultaneously submit a completed site application form for the

Preferred Site or do so within thirty (30) days after the franchise application is approved. If a

completed site application form is not submitted within said thirty (30) days, the application

will be deemed withdrawn by the Applicant. The Company agrees that it will not enter into

an agreement with another franchisee for development of a Checkers Restaurant at the

Preferred Site within the referenced thirty (30) day period. The site application form must be

accompanied by a $4,000 site application fee, which is refundable only if the Company denies

the application for a Checkers Drive-In Restaurant at the Preferred Site.

If the franchise application is denied, Applicant acknowledges and agrees that the

Company has granted no rights whatsoever to the Applicant with respect to the Preferred

Site, and that the Company may own and operate, and grant to others the right to own and

operate, a Checkers Restaurant at or near the Preferred Site.

Applicant represents and warrants that the information contained in this franchise

application is true and correct and fairly reflects Applicant’s financial position as of the date

hereof. Applicant also represents and warrants that his/her assets, property or interests are

not “blocked” under any law or regulations relating to terrorist activities, and he/she is not

otherwise in violation of any such laws or regulations.

Applicant understands that the Company has the right to deny this application if any

of the following events occur:

1. The Company determines that the information in this franchise application is

not true and correct or does not fairly reflect the financial condition of the Applicant, or that

the Applicant is not financially qualified to purchase a Checkers Drive-In Restaurant

franchise.

2

CHECKERS

March 2012

EAST\42859613.1

2. The Company determines for whatever reason that the awarding of a Checkers

Restaurant franchise would not be in the best interest of the Applicant or the Company.

The above determinations are to be made solely at the discretion of the Company, and

Applicant agrees the Company will have no liability for any such determination, other than

the obligation to refund the application fee, less expenses.

If and when the Company approves the franchise application and Preferred Site, the

Company will offer Applicant a franchise to operate a Checkers Restaurant at the Preferred

Site by delivering its then-current form of standard franchise agreement, together with all

standard ancillary documents (including exhibits, riders, collateral assignments of leases,

guarantees, and other related documents) that it then customarily uses in granting franchises

for the operation of a Checkers Restaurant in the state in which the Preferred Site is located.

The franchise agreement and the ancillary documents must be duly executed and returned not

earlier than 7 days and not later than 21 days after they are delivered, with payment of the

initial franchise fee, as required thereunder. The application processing fee and site

application fee are creditable toward the initial franchise fee. If the Company does not timely

receive the fully executed franchise agreement and ancillary documents and payment of the

required initial fees, the Company may revoke its offer to grant a franchise to operate a

Checkers Restaurant. This application does not confer any rights relating to the Company’s

trademarks, service marks or trade dress, which includes the Checkers Restaurant exterior

building appearance and design, menu layouts and advertising slogans and characters. Any

proprietary or confidential information provided by the Company to the Applicant is solely for

the purpose of Applicant’s evaluating a Checkers Restaurant franchise. Applicant

acknowledges that any rights to use such property or confidential information may be derived

only pursuant to an executed franchise agreement, and that unauthorized disclosure, transfer

of use, either direct or indirect, of such information by the Applicant would constitute an

infringement of the Company’s rights thereto and result in irreparable injury to the Company

for which there is no adequate remedy at law.

Applicant represents and warrants that its responses to the following questions are

true as of the date of this application:

1. Have you received a complete copy of the Company’s Franchise Disclosure

Document at least 14 days before the earlier of the date on which you signed this franchise

application or paid the deposit required hereunder?

Yes No Initials

Initials

Fillable Printable Checkers Drive-In Application Form

Fillable Printable Checkers Drive-In Application Form