麦当劳特许经营

是 否 1、您了解目前特许经营方式是转让一家已在营运中的成熟麦当劳餐厅，不需要您自己选地址。

您了解目前特许经营方式是转让一家已在营运中的成熟麦当劳餐厅，不需要您自行选址。

参考指引：目前特许经营方式是转让一家已在营运中的成熟麦当劳餐厅。给予被特许人什么餐厅的决定权是由麦当劳公司掌握的。如果您只有兴趣在您的所在地作特许经营，我们合作的机会就会比较低。但是如果您愿意将您有的房产租赁给我们公司，您可以留下联系电话, 我们会请麦当劳公司地产部来洽谈租赁事宜。

是 否 2、您了解申请流程中必须接受9-10个月的全职训练（或更长时间的兼职训练）和评估，而且必须是您本人参加训练。

您了解申请流程中必须接受9-10个月的全职训练（或更长时间的兼职训练）和评估，而且必须是您本人参加训练。

参考指引：参加为期9-10个月的全职培训计划（或更长时间的兼职培训计划）是为了让您全方位地熟悉麦当劳餐厅的营运，为了让您成为具有有效管理和训练能力的管理者，为了让您知道餐厅必须重视顾客和以人为本的原则，也为了让您可以在特许经营组织内胜任工作。也必须是本人参加训练。

是 否 3、您是否愿意将麦当劳作为唯一的事业，并在经营期内全职对餐厅的日常工作全力以赴。

您了解您本人要全职且对餐厅的日常经营工作全力以赴，不可以找人代替您来经营餐厅。

参考指引：理想的被特许人需要本人全职且对餐厅的日常经营工作全力以赴，所以不可以找人代替您来经营餐厅。

是 否 4、个人拥有至少200万现金或等同现金的股票，债券、房屋等可以变现的资产。 您个人拥有不少于200万资金（指的是现金或等同现金的股票、债券，包括房屋等可以变现的资产）。

参考指引：申请时个人拥有的不少于200万资金指的是现金或等同现金的股票，债券，包括房屋等可以变现的资产。申请人必须准备投资的资金不少于200万人民币，而且必须要以个人的名义投资，也就是申请人必须自己个人拥有足够的财力，而不允许合伙投资。被特许人可以贷款，但是个人拥有的资金最低要求是不少于200万，且这200万不可以贷款。

是 否 5、您了解目前我们可以申请特许经营的城市有：盐城、连云港、常州、扬州、泰州和淮安。

McDonald’s (China) Co., Ltd. 麦当劳（中国）有限公司 Application for Franchise 特许经营申请表

Confidential 机密文件

This Application does not obligate McDonald’s (China) Co., Ltd. in any manner. 此申请表不构成麦当劳（中国）有限公司的任何义务

Please Print Clearly in both English and Chinese to answer all questions 请用工整中/英文填写回答以下问题

I submit the information enclosed in this form as my complete and true personal and financial condition as of the date shown below. I expressly authorize any past or present employer, any law enforcement agency, state or local, or any person who has personal knowledge of my character, work experience, financial condition or criminal records to release this information to McDonald's （China）Co., Ltd. or one of its affiliates (“McDonald’s China”). I understand and acknowledge that, as a condition of being considered for the McDonald's franchisee training program, I must submit to a credit history check to be performed by a credit reporting agency of McDonald's China’s choice. I understand that the credit reporting agency will make the results of the credit history check available to McDonald's and that McDonald's China may use those results in determining whether I will be placed into the franchisee training program or remain in McDonald's franchisee training program. If requested by McDonald's China, I agree to supply statements from my professional advisors (i.e., banker, broker, accountant or attorney) verifying my assets, and I also agree to furnish copies of Income Tax Returns as filed for the last five years. I understand that McDonald's China is relying upon all the above information as a material factor in considering my application to become a McDonald's franchisee, and I therefore agree to promptly notify McDonald's of any material change in any of the above information or any subsequent information provided to McDonald's China. In addition, I release McDonald’s China from liability as a result of true, accurate information. I also certify that neither I nor any of my funding sources, is or has ever been a terrorist or suspected terrorist, or a person or entity described in Section 1 of U.S. Executive Order 13224, issued September 23, 2001, as such persons and entities are further described at the Internet website www.ustreas.gov/offices/enforcement/ofac. I agree to comply with and/or to assist McDonald’s to the fullest extent possible in McDonald’s efforts to comply with the above law.

本人/我们在此提供的信息是截至本申请表填写之日关于本人/我们的个人和财务状况的完整和真实的信息。本人/我们谨明示授权任何本人/我们过 去及目前的雇主、任何或地方有权执法的机关或任何一位了解本人/我们的品格、工作经验、财务状况或犯罪记录的人士将前述相关资料提供给麦当劳（中国） 有限公司(下称“麦当劳中国”)或其关联企业。本人/我们了解作为麦当劳中国考虑本人/我们参加特许经营培训的条件，本人/我们应接受一项由麦当劳中国选 定的信用征信机构进行的信用记录审核。本人/我们了解该信用征信机构将向麦当劳中国提供审核结果而麦当劳中国将以之决定本人/我们能否加入到或保留在麦当 劳特许经营训练计划中。如果麦当劳中国要求，本人/我们同意向专业顾问（如银行、经纪人、会计师或律师）取得并向麦当劳中国提供证明本人/我们的资产的文 件。我并同意提供过去五年的所得税纳税凭证。本人/我们了解麦当劳中国依赖本申请表中所包含的所有信息以决定本人/我们成为麦当劳被特许人的申请之重要因 素，为此本人/我们将就以上信息或之后向麦当劳中国提供的信息的任何变化立即通知麦当劳中国。本人/我们在此免除麦当劳中国基于信赖我们所提供信息的真实 和正确而作出之行为的任何责任。本人/我们申明，无论本人/我们或本人/我们的资金来源均不是且不曾是或被怀疑是或是2001年9月23 日美国总统行政令13224第1条所规定的人或实体（该等人或实体在以下网址www.ustreas.gov/offices/enforcement/ofac有更多描述），并明了任何虚伪不实或遗漏之陈述将导致麦当劳公司拒绝本人/我们申请参加特许经营训练或于授权特许经营后终止特许经营关系。本人/我们愿意遵守并尽最大可能协助麦当劳中国遵守上述法令。 _________________________ _____________________________ Signature (Applicant)/申请人Signature (Spouse)/申请人配偶签字 签字 Date/日期 Date/日期

我已经看过并同意《特许经营申请表》

请选择您所在的地区：

1. Personal Information (个人信息) * 表示必填信息 English Name

英文姓名

Maiden Name or any Alternate * Chinese Name

中文姓名 Names Used 婚前名或曾用名 * Date of Birth

出生年月 Passport No

护照号码

* Home Tel. No. (with area code)

住宅电话号码 (包括区号)

* Personal Email address :

个人电子邮件地址：

* Current home address:

目前的家庭住址：

Previous home address: 前家庭住址： * Nationality (including any dual nationality): 国籍（包括任何双重国籍）： Former

Nationality (if any): 之前国籍（如有的话）： Marital

Status (select

one)

婚姻状况

(选一个)

Spouse 配偶

Single/Never

Married

未婚

Separated Married 分居 已婚

* Place of Birth 出生地点

* Sex

性别

男* I.D. Card No.

身份证号码

* Personal Mobile

个人移动电话

号码

Divorced Widowed 离婚 丧偶

女

English Name 英文姓名 Place of Birth 出生地点 Date of Birth 出生年月

Chinese Name 中文姓名

I.D. Card

No.

身份证号码 Employer (if not working,

Occupation

last

(if not working, last

employer)

occupation)

雇主 (如目

职业 (如目前无工

前无工作,

作, 请列出最后的

请列出最后

职业)

的工作单位)

Present Residential Address 目前居住地址

Child 儿女 +

Chinese

English Name

Name

英文姓名

中文姓名

Place of Birth

出生地点 Date of Birth I.D. Card No.

出生年月 身份证号码

Employer (if

Occupation not working, (if not working, last last occupation) employer)

职业 （如目前无工雇主 （如目作,请列出最后的前无工作,请职业） 列出最后的

工作单位）

2. Education ( 教育背景) Type School 学校

of

Name, address and phone

Subject 专业

From -To 起止

Degree? Y / N 是/否有

Certificate #

证书编号

number of school/university 学校名称,电话号码和地址

Secondary School 中学

Vocational School 职校/技校 University

大学

Other Courses + 其他进修课程 Scholarship obtained + 所获奖学金

Other

Professional

Qualifications +

其他专业资质

时间

学位? (请列出)

Y N

Y N

Y N

Y N

Y N

Y N

3. Business Experience（商业经验） Present occupation目前职业状况：

* Position职位： * Company公司名称： * Address地址：

* Telephone number电话： Fax number传真： Website address网址：

* Dates employed起始日期：

Describe duties, number of employees supervised

描述工作职责及所管理的员工数量：

Previous business experience (List most recent first.)

过去的商业经验（从最近的开始）

* Have you ever owned your own

business or franchise? If so, explain. 是否曾拥有自己的生意或特许经营店？ 如是，请介绍：

* Have you ever had a business failure? If so, explain 是否曾经历生意经营失败？ 如是，请介绍：

4. Miscellaneous Information（其他) * The flexibility to relocate may be required。 To which general geographic area（s）would you be willing to relocate for a restaurant opportunity可以前往特许经营之县市/省 (请依个人意愿依先后顺序填写)

List any hobbies， community activities， special interests or other pertinent information列出您的嗜好、常参加的小区活动、特别兴趣或其它相关的信息

* Are you related by blood or marriage to any officer of McDonald‘s China是否有亲戚在麦当劳任职？ 是 否

* Have you ever worked in a McDonald‘s restaurant？If so， where and when？您曾在麦当劳餐厅工作过吗？如果是，何时？在哪家餐厅？

* Have you ever applied for a McDonald‘s franchise？ If so， where and when？您曾经申请参加麦当劳特许经营吗？如果是，何时？

5. Please list at least 2 references. We may contact them for further information regarding your information (请列出至少两位最能评估您过去的表现与实力的人士。本公司在必要时可能会与他们联络，以进一步了解您的情况) * 姓名 Name

6. PERSONAL FINANCIAL STATEMENT/个人资产状况 （Significant Property Holdings and Business Interests.(所拥有的较大价值的财产以及从事的其他商业活动)

INCOME STATEMENT FOR 12 MONTH PERIOD ENDING 截至 年 月，12个月期间的收入状况 Salary, wages, bonus, commissions

RMB $

工资、奖金、佣金 Dividends, interest

股息、利息

Other income - specify source, e.g., business profits (self-employed), trust, etc.

其他收入，列出具体来源，如自有生意的利润、信托投资收益等 * TOTAL

RMB $

总额

Please provide details on the following asset verification schedules schedule numbers in parentheses) 请提供以下资产清单 .

Assets/资产 RMB $ Liabilities/负债

Cash on hand and in

Loans/notes/accounts

banks RMB $

payable

现金及银行存款总额

借款/票据/应付款 Real estate

Vested profit sharing

RMB $ mortgages

分得的利润

不动产抵押

Securities, Other debts or Bonds/debentures RMB $ obligations 证券和债券 其他负债或义务 Notes, accounts and mortgages

RMB $

receivable 票据、应收款

* 单位 Company

* 职位 Position

* 关系 Relationship

* 联系电话 Telephone

RMB $

RMB $

RMB $

RMB $

Real estate-current market value RMB $ 不动产-市场现值

Net value of business interests RMB $ 自有生意的净值

Other-automobiles and other

RMB $

personal property, etc. 其他-汽车和其他动产 * Total assets/总资产

7. Please answer the following (请回答以下问题) RMB $

* Total liabilities/总负债 RMB $

Net Worth/净资产 RMB $

7.1 CIVIL/CRIMINAL LITIGATION AND REGULATORY MATTERS/民事诉讼刑事诉讼和其他法律事项

* Have you, your spouse, or any business concern you ever controlled, were employed by, served as an officer or director of, or had an ownership interest in,

ever been arrested or charged with any crime or offense (other than minor traffic violations)? If yes, provide the following information with regard to any indictment, information, accusation, summons, complaint, arrest or conviction below. /您、您的配偶或您曾控制、受雇、任董事或高级管理职位或持有所有益的任何商业组织是否曾被捕、被控刑事犯罪或违法（轻微之交通违章事件除外）

* Have you, your spouse, or any business concern you ever controlled, were employed by, served as an officer or director of, or had an ownership interest in, been a plaintiff or defendant in any civil matter in a court of law (including debt collection matters or bankruptcy proceedings) or been the subject of a judgment? If yes, provide the details below. / 您、您的配偶或您曾控制、受雇、任董事或高级管理职位或持有所有益的任何商业组织是否曾作为任何民事审判（包括债务追偿和破产程序）的原告或被告或者 是一项判决的被执行方？

* Has a bankruptcy petition ever been filed for you, your spouse, or any business concern you ever controlled, were employed by, served as an officer or director of, or had an ownership interest in? If yes, provide the details below, including the name of the petitioner, the date of the petition and where that petition (jurisdiction) was filed/是否曾发生针对/您、您的配偶或您曾控制、受雇、任董事或高级管理职位或持有所有益的任何商业组织的破产申请？如果是，请提供细节，包括 申请人、申请时间和地点（管辖地）。

* Have you ever been involved with non-routine governmental inquiries, investigations, criminal proceedings, regulatory or enforcement actions in any country? If so, please explain in detail, providing all relevant dates and a description of the reason(s) for the investigation or proceeding, the conduct alleged, the names and addresses of the persons involved, the name and nationality of

the investigating or law enforcement entity, the result of the investigation or proceeding, including any penalties imposed, any ongoing legal disabilities imposed, and any other relevant information (use additional sheets as necessary)/您是否在任何国家曾受到非常规的询问、调查、刑事程序，监管或强制措施？.如是，请详细解释，提供所有有关的日期和关于该等调 查或措施的原因、受质疑的行为、涉及人员的名字和地址、调查或执法机关的名称和所属国、调查或措施的结果，包括给予的处罚、持续有效的法律，以及如何 其他有关信息（如有需要请使用额外的纸张）。

7.2 U.S. Foreign Corrupt Practices Act and Local Anti-Corruption Laws/美国海外反法和当地反法律

* Are you aware of the requirements of the U.S. Foreign Corrupt Practices Act and international or local anti-bribery laws? /您是否了解美国海外反法和国际或国内的反贿赂法律？

* Have you ever offered, promised, or received requests for payments of any kind, gifts, or unreasonable entertainment of or from government officials or employees? If yes, please describe the circumstances of the offer, promise or request and how you responded to it/您是否曾提出或承诺或被要求对或雇员给予任何形式的给付、礼物或不合理的招待？如是，请描述提出或承诺或被要求的情形以及你如何回应该等要 求。

* Have you ever been involved in a violation (either alleged, charged, investigated or indicted) of the U.S. Foreign Corrupt Practices Act, any national anti-bribery law or been investigated and/or debarred by the World Bank or government entity? If yes, explain/您是否曾涉及违反美国海外反法或任何国家的反贿赂法或受到世界银行或机构调查和/或禁制？如是，请解释.

* Please indicate if you or any of your immediate family can be categorized as one or more of the following (“Immediate family” means parents, brothers, sisters, children and each of their spouses): a current or former official or employee of a national, provincial or local government or government entity; a current or former official of a political party; a current or former candidate for public office; a current or former employee, director or manager of any state-controlled or state-owned enterprise. (State-controlled and state-owned enterprises include any business that is owned or controlled by any national, provincial or local government.); a current or former employee or official of a public international organization, such as the World Bank, the International Monetary Fund, the United Nations, the Asian Development Bank and the European Union; or a current or former official with any consulting, ceremonial or titular positions for any government entity. If yes, please provide the name of the person holding the position and dates and position held/请陈述您或您的任何直接家庭成员（指父母、兄弟、姐妹、子女及其各自的配偶），以及是否可归类为：国家、省或地方或部门的现任或前 或雇员；政党的现任或前；公职的现在或前候选人；国有或国家控制的企业的现任或前雇员、董事或经理 (国有或国家控制的企业包括国家、省或地方拥有或控制的任何商业组织)；公共国际组织如世界银行、国际货币基金组织、联合国、亚洲开发银行和欧盟的现 任或前雇员或；或任何机构的顾问性、名誉或名义职位的现任或前。若是，请提供任职者的名字和任职的日期和职位。

* Have you, any business concern you ever controlled, or directors/shareholders of any business concerns you controlled contributed to the campaign of a political candidate? If so, please name the

candidate, the amount contributed and the dates of all contributions made within the past 10 years/您或您所控制的商业组织或其董事或股东是否曾经向任何政治候选人捐款？如是，请列出该候选人的名字、过去十年内所有捐款的金额和日期。

* Please list any other background information that might indicate a relationship with or connection (present and past) to a government or state owned entity, political entity or international organization about which you feel we should be aware/请列出其他您认为我们应该了解的、任何可能涉及与或国有机构、政治组 织或国际组织的关系或联系的背景资料。