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Preliminary Review

Now that you've had the opportunity to acquire a basic overview of the advantages of being an LA Weight Loss Centers franchisee, you can gain access to more in-depth specifics about partnering with LA Weight Loss. To do so, please complete this brief Review Form.

Personal Information

Title:	Mr. Mrs. Ms. Dr.
First Name:
Last Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
Email Address:
Date of Birth:
Home Phone:	*Outside of the U.S.A., please include your country code.
Work Phone:	*Outside of the U.S.A., please include your country code.
Spouse's Name:

Employment
Please list most recent employer (full-time only) or business you own

Owner or Employee:	Owner Employee
Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
Title:
Annual Earnings:
Products/Services:
Additional Comments/Related Weight Loss Experience:

Sources of Capital

Net Worth:
Identify sources of capital to be used to fund your LA Weight Loss Centers franchise:

Areas of Interest
Choose your primary and secondary location choices

First Location:
Second Location:
International Interest:

General Information

When are you looking to open a franchise:	3 months 6 months 1 year
Time willing to devote to business:	Full Time Part Time Absentee
Are you willing to relocate:	Yes No
When is the best time/place to contact: