Dollar Store Initial Qualification Form

Simply fill out the information below and click the Set Up button.
Required entries are shown in green.

E-mail address	(required)
Full name (e.g., John H. Doe)	(required) First M. Last
Company	(optional)
Address	(required)
City	(required)
State	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau (required)
Zip Code	(required)
Country	(required)
Primary phone #	(required)
Evening phone #	(optional)
Fax #	(optional)

Time to Call:
Optional Info
How did you first hear about DollarStore, Inc.?	Business Associate Friend or Family Member Internet Site Magazine Ad Radio Ad Trade Show or Event Other
I am most interested in:	Not Selected Buy Merchandise Sell Merchandise Store Set Up Franchise Store Operation System POS Close outs Items Investment
Highest level of education:	Select an education High School College Graduate School Other
Annual household income:	Under $25,000 $25,000-$35,000 $36,000-$49,000 $50,000-$75,000 Over $75,000
How soon would you like to open your own business?	Less than 90 days 3 to 6 months 6 to 12 months More than 1 year
Amount of liquid capital available?	$25,001 - $50,000 $50,001 - $100,000 $100,001 and up
Approximate net worth?	$50,001 - $99,999 $100,000 - $199,999 $200,000 and up

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