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Confidential Application

Hometown Store

Confidential Application

Fax completed application to: 1-847-286-7480 or Mail to: Sears Hometown Stores D/700-1DS B4-159B 3333 Beverly Road Hoffman Estates, IL 60179 Sears Recruiting Information Number: 1-888-259-2616 For additional information or to apply online, visit our website at:

www.searshometownstores.com


Hometown Store

Confidential Application (Please complete in black ink) Date

PERSONAL DATA Full Legal Name (no abbreviations or nicknames) Last Five Digits of Your Social Security Number Address (principal residence)

City/State

Zip

Driver's License Number

State Issued

Are you a U.S. citizen? Yes � No � If you are not a U.S. citizen, please describe your visa status. __________________________________________________________

Home Phone ( Fax Number (

)

Business Phone (

)

Cell Phone (

) )

e-mail I.D. (required) Previous Address (If less than five years at above address) City/State/Zip

Where or how did you hear of this opportunity? Which market location have you selected? (Required) Have you ever owned your own business?

City/State

Yes �

No �

If yes, describe (Including sales volume and earnings)

EDUCATION

High School Graduate

Yes �

No �

Grade Point Average

College Graduate

Yes �

No �

Grade Point Average

Special Activities/Interests/Membership (Civic, business, professional) List Activities

For immediate consideration fax to 1-847-286-7480


BACKGROUND Have you ever been convicted of a felony or misdemeanor, other than a minor traffic violation?

Yes �

No �

If yes, please state facts: Have you ever declared bankruptcy?

Yes �

No �

Yes �

No �

If yes, please state facts: Has a civil judgement ever been rendered against you? If yes, please state facts: Have you ever been employed by Sears, Roebuck and Co.? Yes � Have you ever been employed by a Sears Hometown Store? Yes � Have you ever owned a Sears Hometown Store?

Yes �

No �

No � No �

If yes, Please list Unit Number If yes, Please list Unit Number

If yes, Please list Unit Number

How many hours per week do you plan to devote to the business? Who will operate the store? Will other persons have an ownership interest or be involved in the management of the store? If yes, who:

Name:

Relationship:

(Spouse, Partner, Other-Describe)

Yes �

BUSINESS/WORK EXPERIENCE (last 10 years)

Present Occupation

Position

Dates Employed

Company

Address

City/State

Occupation

Position

Dates Employed

Company

Address

City/State

Occupation

Position

Dates Employed

Company

Address

City/State

Occupation

Position

Dates Employed

Company

Address

City/State

Describe duties, number of employees supervised and responsibilities

Describe duties, number of employees supervised and responsibilities

Describe duties, number of employees supervised and responsibilities

Describe duties, number of employees supervised and responsibilities

For immediate consideration fax to 1-847-286-7480

No �


ASSETS AND LIABILITIES ASSETS

LIABILITIES

Cash

$

Loans

$

Real Estate (Current market value)

$

Real Estate

$

Savings

$

Income Tax Payable

$

Securities

$

Mortgages

$

Automobiles

$

Credit Cards

$

Others (describe)

$

Car Loans/Lease

$

Other Debts or Obligations

$

TOTAL ASSETS

$

TOTAL LIABILITIES NET WORTH

Total cash available without borrowing

$ $

Other cash assets not described:

PROPERTY Do you own or rent your principal residence?

Own �

Do you own real estate other than your principal residence? Address and Type of Property (Include private residence) Mortgage Holder

Year Aquired

Address and Type of Property Mortgage Holder

Year Aquired

Address and Type of Property Mortgage Holder

Year Aquired

Rent � Yes �

Monthly Mortgage/Rent Payment

No �

$

If yes, identify below

Title In Name of

Monthly Mortgage Payment $

Mortgage Balance $

Present Market Value $

Ti t l e I n Name of

Mon t h l y Mortgage Payment $

Mortgage Balance $

Present Market Value $

Ti t l e I n Name of

Monthly Mortgage Payment $

Mortgage Balance $

Present Market Value $

BANK REFERENCES Name under which your account appears Bank/Address

City/State

Bank/Address

City/State

Bank/Address

City/State

CREDIT CARDS Name

Balance Due

Payment

_________________________________________________________ ____

___________________________________ ____

___________________________________ ____

_________________________________________________________ ____

___________________________________ ____

___________________________________ ____

_________________________________________________________ ____

___________________________________ ____

___________________________________ ____

_________________________________________________________ ____

___________________________________ ____

___________________________________ ____

Other Credit References

For immediate consideration fax to 1-847-286-7480


ASSETS AND LIABILITIES Describe below, in detail, why you are interested in becoming a Sears Hometown Store Owner (Required).

This application does not constitute an offer to become a Sears Hometown Store Owner. It is strictly an application to be an independent Sears Hometown Store Owner. It does not constitute an application for employment. The undersigned acknowledges that operating an independent Retail Dealership has no guarantee of success and that Sears makes no representations as to the business risks associated with owning and operating a Hometown Store. The risks and rewards, if any, are primarily dependent on the individual operator. The undersigned represents and warrants that the information furnished is full, truthful and accurate. The undersigned authorizes Sears or its designated representatives to do the following as part of the application process and, if applicant is selected as a Sears Hometown Store Owner and enters into a definitive Hometown Store Agreement with Sears, as part of any review of applicant’s financial status during the term of the Hometown Store Agreement and any successor agreements thereto: • • • • •

obtain consumer credit reports, including investigative consumer reports;* obtain commercial credit reports; conduct a background investigation, including the verification of any information furnished by the undersigned; contact any references noted; and provide any and all information contained in this application or obtained from any credit report, background investigation or references, to any financial institution requesting such information for purposes of providing financing related to Hometown Stores to the undersigned.

* These reports will provide, among other things, information on the character, general reputation, personal characteristics, or mode of living of the undersigned and may be obtained through personal interviews with neighbors, friends, or associates, or with others with whom the undersigned is acquainted or who may have knowledge concerning any such items of information.

Signature

Date

Print Full Legal Name

Fax completed application to: 1-847-286-7480 or Mail to: Sears Hometown Stores D/700-1DS B4-159B 3333 Beverly Road Hoffman Estates, IL 60179 Sears Recruiting Information Number: 1-888-259-2616 For additional information or to apply online, visit our website at:

www.searshometownstores.com


Application