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Franchise Application Form

*(Complete in full and do not use abbreviations.)

*The filling of this application does not oblige the application to become a franchise of Old town White Coffee.

Personal Info
Marital Status
Spouse occupation
Total dependant

Employment / Business Experience

Do you plan to have Equity partner

 Yes No

Schedule A - Financial (Cash on Hand and in Bank)
Name of Bank/Financial Institutions Country Amount
Schedule B - Cash Value of Life Insurance
Name of Insurance Company Face Amount Cash Value
Schedule C - Real Estate Owned
Description of Property Name on Title Cost Market Value Balance Owned Mortgage Holder


List 3 (three) references you have known for at least 5 years.

Name Address Relationship Contact No.

List all businesses in which you have financial interest.

Name Address Position Year Started Shareholding Percentage

Personal Financial Statement


I understand that the granting of franchise is at the sole discretion of Oldtown White Coffee.

I understand that I and/or representatives will have to be successfully complete Oldtown White Coffee's training program and competent to operate prior to the start of business operations.

I have read this application and everything I have stated in it is true. I understand that Oldtown White Coffee, in granting me a franchise, will rely upon the information provided by me.

 I agree

I hereby authorise Oldtown White Coffee, its agent and all credit agencies, educational institutions, corporations, current and former employers, law enforcement and government agencies, city state, country and federal courts, military services and persons to release any information they may have about me to the company with which this has been field, or their agent.

I release Oldtown White Coffee and/or its agents and any person or entity which provided information pursuant to this information, from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all referenced sources used.

 I agree

Option 2

You may download the form and mail the form to

Business Development Department
Oldtown Indonesia
Komplek Multiguna Blok A7 Jalan Raya Serpong Km.7
Tangerang Selatan – 15310, Indonesia

Fax  : 021 – 5399241
Telp : 021 –5399240 / 08176763998
Mail :

Download Franchise Application Form