1. Have you ever owned a franchise?  Yes     No      Name of franchise:
   Rate your franchise experience (1-5, 5 being best): 1 2 3 4 5    Year:    Contact:
2. Are you exploring other franchise opportunities?  Yes     No If Yes, which ones?
3. Would you expect to devote full time to the business?  Yes     No     If not, what % of time?
4. Do you have, or can you obtain, the necessary cash funds to invest in the business?  Yes     No
   Please explain in detail:
5. Do you regard an ITEX franchise as:  Investment     Career     Speculation
6. Would you employ a full-time manager?  Yes     No
7. If selected, when would you be able to start this opportunity?
8. What marketplace are you interested in?
9. Have bankruptcy proceedings ever been instituted against you?  Yes     No
   If yes, please explain:
10. Are you now, or have you ever been, party to any suits or civil actions?  Yes     No
    If yes, please explain:
11. Have you ever been convicted of a crime other than minor traffic offenses?  Yes     No

By submitting this form, I certify that the information contained in this Franchise Qualification Form is accurate and complete to the best of my knowledge. We may conduct investigations and make inquiries of any person or persons we, in our reasonable judgment, believe appropriate concerning the credit standing, character, and professional and personal qualifications of you and your owners, shareholders, members and partners. You authorize us to conduct these investigations and to make these inquiries. We agree to comply with the requirements of laws that apply to these investigations and inquiries. All information will be held in strict confidence. The completion of this form will not oblige ITEX Corporation or me in any manner.