P r i ma r y A p p l i c a n t

F i r s t N a me * A d d r e s s * C i t y *

C o mp l e t i o no f t h i sa p p l i c a t i o nd o e sn o t o b l i g a t ey o uo r R a c e Wa y , I n c . T h i ss i t ea n dy o u r i n f o r ma t i o na r e s u b mi t t e ds e c u r e l y .

a s t N a me * M. I . *L

P r i ma r y P h o n e *

S e c o n d a r y P h o n e

F a x S t a t e *
Alabama

Z I PC o d e *

E ma i l A d d r e s s *

S o c i a l S e c u r i t y N u mb e r *

D r i v e r s L i c e n s e # *

D a t e o f B i r t h *

I f y o uw e r e r e f e r r e dt oR a c e Wa y , b y w h o m:

High School

L i s t a l l b r a n d ( s ) o t h e r t h a nR a c e Wa y t h a t y o uo w no r o p e r a t e o r h a s o w n e do r o p e r a t e di n t h e p a s t : S t i l l O w n e d ? S t i l l O w n e d ? o r f r a n c h i s e ? * N o N o N o

Y e s Y e s

H a v e y o ue v e r h a da no p e r a t o r s o r f r a n c h i s e a g r e e me n t t e r mi n a t e db y t h e c o mp a n y

Y e s

N o N o N o

H a v e y o ue v e r b e e nc o n v i c t e do f a f e l o n y o r p l e a dn o l oc o n t e n d r e t oa f e l o n y c h a r g e ? *

Y e s Y e s Y e s

H a v e y o ue v e r d e c l a r e db a n k r u p t c y ? * A r e y o u a p a r t y t o a c o n t r a c t w h i c h i m p o s e s n o n c o m p e t i t i o n r e s t r i c t i o n s o n y o u r b u s i n e s s a c t i v i t i e s ? * A r e y o u c u r r e n t l y p r o v i d i n g p r o d u c t s , g o o d s , o r s e r v i c e s t o R a c e T r a c P e t r o l e u m, I n c . o r a n y o f i t s o p e r a t o r s ? * N o Y e s H a v e y o ua p p l i e dt oo p e r a t e a R a c e Wa y s t o r e b e f o r e ? *

N o

Y e s

SUPPLEMENTARY SCHEDULES No. 1 - Banking Relations (a list of all my bank accounts, including savings and loans.) Name and Account # Cash Outstanding Loans Location of Bank Balance Maturity Date How Guaranteed

No. 2 - Accounts Receivable (a list of the largest amounts owed to me.) Name & Address Amount Owing Age of Debt of Debtor

Nature of Debt & Security Held

Date of Payment

No. 3 - Life Insurance Name of Person Insured

Policy #

Name of Beneficiary

Insurance Company

Face Amount of Policy

Total Cash Surrender Value

Total Loan Against Policy

Is Policy Assigned

Type of Policy

Amount of Yearly Premium

No. 4 - Stocks, Bonds, and Mutual Funds Face Value Description Due Date (Bonds) of Security No. of Shares (Stocks)

Registration in Name of and #

Cost

Present Market Value

Income Received Last Year

To Whom Pledged

Brokers Name(s) Indicate on each if stocks or bonds are held by the broker (B) or by yourself (S)

Balance of Margin Account(s)

_________________________________________________________ _________________________________________________________ _________________________________________________________

__________________ __________________ __________________

No. 5 - Real Estate (legal and equitable title to all real estate listed in this statement is solely in the name of the undersigned, except as follows) Type of Address Mortgages Mortgage or Due Dates Assessed Present To Unpaid Taxes Property or Liens Lien Held by and Value Market Whom (home, Amounts of Value Pledged Business, Payments land, etc.
Year Amount

No. 6 - Creditors I buy goods principally from: Name of Creditor

Address

ASSETS Cash on hand, and unrestricted in banks (see Schedule No. 1) U.S. Government Securities Accounts and Loans Receivable (see Schedule No. 2) Notes Receivable, not discounted (see Schedule No. 2) Life Insurance, cash surrender value (do not deduct loans) (see Schedule No. 3) Stocks and Bonds (see Schedule No. 4) Real Estate (see Schedule No. 5) Automobiles (registered in own name) Year: Make: Model: Year: Make: Model:

LIABILITIES Notes Payable to banks, unsecured direct borrowings only (see Schedule No. 1) Notes Payable to banks, secured direct borrowings only (see Schedule No. 1) Notes Payable to Others, unsecured Notes Payable to others, secured Loans against Life Insurance (see Schedule No. 3) Accounts Payable Interest Payable Taxes and Assessments Payable (see Schedule No. 5) Mortgages payable on real estate (see Schedule No. 5) Brokers Margin Accounts (see Schedule No. 4) Other Liabilities (itemize)

Other Assets (itemize) TOTAL ASSETS $

TOTAL LIABILITIES (Total Assets minus Total Liabilities)

$ NET WORTH $

ANNUAL INCOME Salary Bonus and Commissions Dividends Real Estate

Last Year $

Previous Year $

CONTINGENT LIABILITIES As Endorser of Co-maker On leases or contracts Legal Claims Provision for Federal Income Taxes Other special debt $

Other (Itemize) TOTAL (Adjusted Gross Income) $

TOTAL

Additional Applicants (optional) Additional Applicant 1

Alabama

Additional Applicant 2

Alabama

Additional Applicants (cont.) Additional Applicant 3

Alabama

Additional Applicant 4

Alabama

T r a d eA r e aI n f o r ma t i o n
S t o r e #

I f y o uh a v e a ne x i s t i n gR a c e Wa y s t o r e i nmi n d , p l e a s e c o mp l e t e t h e f o l l o w i n g :

T r a d e A r e a D e s c r i p t i o no r e x a c t a d d r e s s o f p r o p o s e ds i t e :

S t o r eD e v e l o p me n t I n f o r ma t i o n
Wh a t i s y o u r e s t i ma t e o f t h e p r o j e c t e dd e v e l o p me n t c o s t s f o r y o u r s t o r e ? $ H o wmu c hc a s h / l i q u i dc a p i t a l a r e y o up l a n n i n gt oi n v e s t i nt h i s p r o j e c t ? $ Wh a t i s t h e s o u r c e o f t h i s c a s h / l i q u i dc a p i t a l ?

Wh a t i s t h e a mo u n t o f t h e l o a n / f i n a n c i n gy o ua r e p l a n n i n gt og e t f o r t h i s p r o j e c t ? $

Wh a t i s t h e e x p e c t e ds o u r c e o f t h i s l o a n / f i n a n c i n ga mo u n t ?

B y Wh o m: