Declaration

I do hereby represent that all of the above answers are true and complete to the best of my knowledge and belief. I recognize that PROBE HEALTHCARE is not in any way obligated to franchise healthcare services to me because of our execution of this document. I acknowledge that any false statement on this application shall be considered sufficient cause to deny any further consideration or cause revocation of any signed agreement with PROBE HEALTHCARE. I understand that an inquiry regarding my character, general reputation, personal characteristics, financial background and general fitness for being a PROBE HEATLCARE franchisee may be made as a result of this application.

In addition, by signing below I release any and all former and I or present employers, and any other personal or business references, from any liability whatsoever in connection with PROBE HEALTHCARE attempts to investigate my background and determine my fitness to become a franchisee. I hereby authorize the release of any and all documents, records, and other information pertaining to me to PROBE HEALTHCARE. A copy of this authorization may be used in place of and shall be valid as the original.

I understand that this application is considered active for 60 days from the date below. I understand that PROBE HEALTHCARE reserve the right to reject my application without assigning any reasons whatsoever.

I confirm that I will immediately notify PROBE HEALTHCARE in writing of any changes to my personal data or any other information contained in this form. By completing this form, I consent to your collection, use and disclosure of my personal data for the purposes of evaluating the franchise application, and if my franchise application is approved, then for the further purposes of:

managing or terminating the franchise relationship; and conducting any other business or legal matters related (directly or indirectly) to the franchise relationship and/or operation of the PROBE HEALTHCARE.