First Name:

Last Name:

Address:

City:

State:

ZIP:

Home Phone:

Alternative Phone:

Best Time To Reach:

E-Mail:

Why do you want to become an Authorized Z-CoiL® Retailer?

I own a pair and believe in the product.

I know someone who owns a pair, and I believe in the product.

Other

I understand in order to become an Authorized Z-CoiL® Retailer I will need liquid capital of approximately $79,850 to $151,800, depending on my local market and other variables. (Based on Albuquerque, New Mexico cost-of-living estimates.)

I understand in order to become an Authorized Z-CoiL Retailer, I will need to open a dedicated Z-CoiL^® Pain Relief Footwear^™ retail store having a minimum of 1,000 square feet.

How long have you been looking to start a business?   

If you have a location in mind, what is its city and ZIP code?
    City      ZIP

How did you first become interested in the Z-CoiL^® franchise opportunity?   (Please select your primary source.)

The Franchise Handbook

Franchise Solutions for Women

NASCAR Preview Guide

Magazine Ad

RN CareerSearch 2007

Z-CoiL® Customer Newsletter

Franchise Market Magazine

News Story

www.franmarket.com

Trade Show/Public Event

I own a pair of Z-CoiL® footwear

Z-CoiL® Distributor

Z-CoiL® Website

I know a Z-CoiL® customer

Other:

Application Statement It is understood that the purpose of this pre-application is for information only, and is no way binding upon either the applicant, or Z-Tech, Inc. dba Z-CoiL Footwear. The information I have submitted within this request for information is true and complete to the best of my knowledge and belief.

By selecting AGREE, I agree to the above statement and release Z-Tech, Inc. dba Z-CoiL Footwear from all liability.

AGREE DISAGREE