Expression of Interest Form Please note that in order to allow us to complete our suitability assessment process, it is essential to respond to all questions. Please confine your answers to the spaces provided. All information provided in the form will be treated in the strictest confidence. Name: Address: Home Phone: Are you interested in opening your own clinic or opening in partnership with someone else? Mobile: Email: If in partnership, provide details: Please provide a brief summary of your previous employment/business experience. How long have you been looking for a franchise? Are there any other franchises that you are considering? If yes, provide details: How did you hear about Motivation Weight Management? What is it about Motivation Weight Management that caught your attention? Have you ever completed the Motivation Weight Management Programme? If yes, provide details: Have you had any other experience of Motivation Weight Management? If yes, provide details: Are you particularly interested in a “management” type franchise? Explain: Do you intend to focus solely on running your clinic or have you other business interests? If you have other interests, provide details: What level of investment can you make? Please tick one.  Up to €40,000  €40 – 70,000  Over €70,000 Why do you think that you would make a good franchisee? What locations are you considering? © Motivation Weight Management 2012 / M1043-1