If you prefer you can download this application in Microsoft Word format here
or in Adobe PDF format here

Elements marked with an asterisk (*) are required

Full name (*):

Home address (*):

Post/Zip code:

Home Phone Number (*):

Business Phone Number:

Mobile Phone Number:

Indicate which type of Operation you may be interested in: If you are unsure, please refer to the website or contact us via e-mail: info@chipstix.net
Area Sales Agent
Retail Outlets (current food operators and/or first time business owners)
Mobile Unit (Purchase)
Mobile Unit (Rental Package) (available in some areas only)

Have you ever worked at a CHIPSTIX operation before?
Yes
No

Have you any relatives who are employed by a CHIPSTIX operation?
Yes
No

Please give details of two business or academic references. No contact will be made until you are accepted into the CHIPSTIX network.

Reference #1:
Name:

Address:

Occupation:

Number of years acquainted:

Reference #2:
Name:

Address:

Occupation:

Number of years acquainted:

Have you ever been convicted of a criminal offence?
Yes
No
If yes, please explain:

Please give below details of any illnesses, operations or accidents, giving dates.

E-Mail address (*):

Nationality:

Date of birth:

Do you hold a current driving license?
Yes
No

Where did you hear about CHIPSTIX trading opportunities?

Why do you think you are suited to becoming a CHIPSTIX Operator?

Will you be devoting your full time to the business?
Yes
No

In which geographic area would you be most interested in running a CHIPSTIX operation?

Have you ever had any experience in the food industry?
Yes
No
If yes, please explain:

Do you have any other business interests?
Yes
No
If yes, please describe:

Have you or your spouse ever declared personal bankruptcy?
Yes
No
If yes, please explain:

Have you ever had a business failure?
Yes
No
If yes, please explain:

Have you ever suffered from, or been a carrier of, typhoid, paratyphoid or other salmonella infection, amoebic dysentery, staphylococcal infection or any disease likely to give food poisoning?
Yes
No
If yes, please give details:

I hereby declare that, to the best of my knowledge and belief, the above statement and particulars are true and complete. I also authorise you to make any enquiries you consider necessary in connection with this application. I undertake to furnish any alterations to the above particulars should I apply for further credit at any future time. I am aware that, should this application be refused, no reason need be given. I understand that any misrepresentation of factual information requested on this application form may be a cause for removal from the CHIPSTIX system.