Personal Details
* First Name:
* Last Name:
* Phone:
* Address1:
* Zip:
* City:
* State:
Business Details
* Business Name:
* No of Locations:
* Type of Operation:
* Years of Operation:
Who is your main food distributor:
Does your business have any of these?
Buffalo Chicken Wings:
Chicken Tenders:

I hereby authorize Cluck-U, Corp. and its agent(s) to thoroughly investigate my background, employment record, criminal record, credit history, and other matters related to my qualifications for a Cluck-U Chicken Brand unit. I authorize any person, including my current employer (if applicable), previous employers, credit reporting agencies, or other reporting persons or organizations contacted by Cluck-U, Corp. to provide any relevant information regarding this application or my history.

I waive my rights under the Privacy Act, 5 U.S.C. 552a and similar state laws.
By submitting responses to this questionnaire, I agree that Cluck-U, Corp. many rely on my responses.

I understand that misrepresentation or omission of facts may result in rejection of my application. By typing my name and submitting this questionnaire, I agree to all the preceding terms.


* Name:
* Date
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