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Prospective Franchisee's details
Full Name:
Address:
Telephone:	Home:		Business:
Email:
Date of Birth			Marital Status:
Spouse/Partner's Name:			Age of Children:

Are you a pharmacist? (Laws in Australia require you to be a pharmacist to own a pharmacy)	Yes No
Have you looked at our V Pharmacy website?	Yes No
Have you visited any of our Pharmacy locations?	Yes No
If so, which location did you visit and what are you initial comments / thoughts?
As a prospective franchisee are you looking to actively work in the pharmacy on a full time basis?	Yes No

Do you Currently:
Own a pharmacy that you want to convert to the V Pharmacy brand?	Yes No
If Yes what brand is it currently?
Work as a pharmacist and want to own and run your own V Pharmacy?	Yes No

Have you had previous:
Pharmacy management experience?	Yes No
Staff management experience?	Yes No
Customer service and sales experience?	Yes No
If so, please provide an overview of your role and responsibilities:

Are you looking to convert an existing pharmacy to the V Pharmacy Brand?	Yes No
If yes, do you have access to start-up capital of at least $250,000?	Yes No
The total conversion cost will exceed this amount but some financing should be available to you to assist in paying for the conversion.

Are you looking to establish a Greenfield V Pharmacy?	Yes No
If yes, do you have access to start-up capital of at least $400,000?	Yes No
The total establishment cost is greater than $400,000. A discussion around financing a portion of the establishment costs will be held at a later stage

Where did you hear about the franchise opportunity?	Web Other Pharmacists Newspaper Advertising Other
The name (if applicable) of the person who introduced you to the opportunity
What are your preferred pharmacy locations? (in order of preference) eg shopping centre, strip shop, rural	1. 2. 3. 4. 5.
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V Pharmacy Head Office - Cairns Australia
Po Box 1013, Smithfield 4878
P: (+61) 07 4038 8900 - F: 07 4038 1244 - E: vcentral@vpharmacy.com.au