Confidential Distributor Questionnaire First Name:    Last Name:    Email:            If our program meets or exceeds your expectations, would you be willing to expand? Yes No

If you found your ideal business, would you be able to start immediately? Yes No

Have you had prior interest in operating your own business? Yes No

How long have you been looking to start a new business? None Selected One Week One Month Three Months Six Months One Year More Than One Year

Have you ever owned or operated your own business? Yes No      If yes, what type?

In terms of investing in a business I am... None Selected Mildly Interested Very Interested Ready to Purchase

Do you have any experience in... Marketing Project Management Management Finance Consulting/Sales Other

Do you plan to have any partners? Yes No      If yes, please submit a complete questionnaire for each person participating in the business.

What is your highest level of education? None Selected GED High School Diploma Bachelors Degree Masters Degree Doctorate Degree Other

If you are chosen for our program, how much do you have to invest towards your business? None Selected $0 - $5,000 $5,000 - $10,000 $10,000 - $20,000 $20,000 - $30,000 $30,000 - $50,000 $50,000 - $75,000 $75,000 - $100,000 $100,000 - 150,000 $150,000 +

Pick the answer that most describes you. None Selected Passive Aggressive Outgoing Precise

Pick the answer that most describes you.  None Selected Confrontational Adaptable Nonchalant Carefree

Pick the answer that most describes you.  None Selected Trusting Satisfied Positive Tranquil

Pick the answer that most describes you.  None Selected Restless Friendly Popular Orderly Set Your Cash Flow Goals - • First, enter in the number of vending machines you will have working for you (packages start at 25 machines) • Then enter how many estimated vends per day you think they'll generate in a location. • Then, enter the average sale price per vend (Revive Energy Mints vend for .50) • Finally, click on Calculate to see your potential gross revenue!

Enter Total Number of Revive Machines Estimated Vends Per Day * Average Sale Price Per Vend    Daily Sales Weekly Sales Monthly Sales Annual Sales *Our company does not guarantee actual earnings, estimated vends per day, or average days to empty. The gross revenue calculations created by using the calculator are determined by the amounts you enter into the calculator fields. Such results are not a representation by Revive Franchising of your future financial performance, or a representation or suggestion by Revive Franchising of your future sales, income, gross or net profit  Additional Comments: Disclosure: This is not a contract or a binding agreement. This does not guarantee your acceptance as a qualified and authorized Revive Energy Mints distributor. This is a receipt acknowledging you are applying for a Revive Distributorship and have received an electronic copy of disclosure statements via email (electronic delivery of disclosure documents). By clicking on "Submit," you certify that you are the person identified on this form and that the information provided to Revive Franchising, LLC in this form is true and correct. In addition, you acknowledge and agree that you have received an email from Revive Franchising, LLC containing an attachment of the appropriate disclosure document to the initial email address provided to Revive Franchising, LLC, and therefore Revive Franchising, LLC has delivered such disclosure document to you and you were able to view and access the disclosure document.  If you were not able to access disclosure document, please call us directly before submitting your application 1-866-393-0387 to request the disclosure in another format.  By submitting your application, you acknowledge and agree that you have received the disclosure.   First Name: Last Name: Initials: Date: