Chuck's Roadhouse Franchising

Personal Information Form - Confidential

    Available Investment

    Business Experience

    Previous Business Experience:

    Start Date

    End Date



    General Information


    Personal Financial Statement

    Present Annual Income (What asset could be used to meet your cash portion of the franchise?)

    Assets (nearest 000's)

    Liabilities (nearest 000's)

    Schedule No.1 - Real Estate

    Personal References

    At least one reference is required

    Obsidian Group Inc. (“Obsidian”) collects, holds, uses and discloses personal information (“information”) about prospective franchisees for the purpose of evaluating prospective franchisees and granting franchises. The files containing such information are kept at Obsidian’s office located at 1770 Argentia Rd, Mississauga, Ontario L5N 3S7.

    Such information may be used to evaluate prospective franchisees in the granting of a franchise.

    Individuals can, at any time, refuse or withdraw their consent to the purpose described above or access their file by contacting Obsidian as follows:

    (i) by telephone at (905) 814-8030
    (ii) by fax to (905) 814-8272
    (iii) by mail to 1770 Argentia Rd Mississauga, ON L5N 3S7

    And advising of their refusal or their withdrawal of consent. All information will be kept and stored in compliance with Obsidian’s corporate policy.

    If I have provided information about any other person(s) in this form, I represent and warrant that the other person(s) has/have provided his/her/their consent to the collection, use and disclosure of his/her/their personal information for the purposes outlined above and that the information about other person(s) financials and otherwise, is true and correct to the best of my knowledge.

    I hereby represent and warrant that all of the information, financial and otherwise, disclosed in this Personal Information Form is true and correct to the best of my knowledge and further covenant to notify Obsidian in the event of any material change in the information furnished by me. I understand this information is to assist in evaluating the possibility of applying for and being granted a franchise. I hereby consent to the collection, use and disclosure of this information by Obsidian. This form is not a contract or an application for a franchise