Name *

E-mail Address *

Company Name:

Date of Birth: *

City: *

State/Prov: *

Zip/Postal Code: *

Cell Phone

Home Phone:

Work Phone:

Indicate Your Net Worth (U.S. dollars) *

Under $250,000 $250,000 to $500,000 $500,000 to $750,000 $750,000 to $1,000,000 $1,000,000 and above

Indicate Your Annual Income (U.S. dollars) *

under $50,000 $50,000 to $100,000 $100,000 to $200,000 $200,000 to $300,000 $300,000 to $500,000 Over $500,000

Check here if you are a plastic surgeon, physician or other medical professional

Check here if you've had experience managing a business

check here if you have no prior management experience

Check here if you currently own a cosmetic clinic, spa or similar beauty-related business

Check here if you wish to be a "Silent Hands-off" Investor

Indicate Total Cash You Have Available to Launch Your Möcelle Edan Cosmetic Clinic (U.S. dollars) *

Under $100,000 $100,000 to $200,000 $200,000 to $300,000 $300,000 to $500,000 $500,000 to $1,000,000 $1,000,000 and above

If You Own an independent/non-franchise cosmetic clinic or medical spa and wish to convert it to Möcelle Edan Cosmetic Clinic, please enter the website and business address of your practice or medspa here.

Why are you interested in having a Möcelle Edan Cosmetic Clinic? *

Please summarize your business experience (be sure to highlight any experience you have in the beauty or healthcare fields) *

In What City and Neighbourhood(s) Would You Most Like To Have a Mocelle Edan franchise? (please state why and if there is any competition in the area) *

Are You Presently part of a franchise system? *

Yes No I was in the past

If You Were Previously Part of a franchise system, please state which one and why you are no longer in the system

Is There Anything Else You Feel May Be Relevant To This Application

Are You or A Company of Which You were/are An Officer or Director, Presently Undischarged From A Past Bankruptcy? *

Yes
No

Have You Ever Been Convicted of A Crime? *

Yes
No

Are You Presently Involved in any Civil, Arbitration or Criminal court proceeding, or is there any judgement outstanding against you? *

Yes
No

If You Answered Yes to Any of the Above Questions, then please explain in detail the circumstances

Please Verify that your information is correct and true; then Select CheckBox at left before submitting. I declare that the information submitted in this application is true, and i authorize Möcelle Edan or its delegate(s) to obtain credit and personal information on me to assess my suitability as a potential franchisee.

* Fields marked with an asterisk are required fields

Please read and verify your agreement(by checking the left box) with our Privacy Policy before sumbitting. I have read and agree to the Privacy Policy (Opens in a new window)

All information contained herein is CONFIDENTIAL and will be used only for the purpose of evaluating your suitability as a potential Möcelle Edan franchisee.     All franchise candidates will receive consideration irrespective of ethnicity, creed, culture, racial or religious background, nationality, gender, sexual orientation or appearance.

The submission of this form does not obligate you to Möcelle Edan in any way whatsoever, no does it imply that their is a legal or commercial relationship between you and Möcelle Edan.    Möcelle Edan reserves the right, in its sole and unfettered discretion, to approve or decline your application for any reason.    In the event your application is decline, we shall in no way be liable to you for anything whatsoever no are we under obligation to contact you to inform as to our decision.     We may contact some applicants for further information, and doing so does not constitute an acceptance of their application.