Acknowledgment

I/WE recognize that Healthy Boost, Inc., is not in any way obligated to License a Healthy Boost Kiosk or promise of employments to ME/US because of MY/OUR execution of this document. I/WE 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 Healthy Boost, Inc. I/WE understand that any inquiry regarding MY/OUR character, general reputation, personal characteristics, financial background and general fitness for being a Healthy Boost License may be made as a result of this application. In addition, by signing below I/WE release any and all former and/or present employers, and any other personal or business references, from any liability whatsoever in connection with Healthy Boost's attempt to investigate MY/OUR background and determine MY/OUR fitness to become a Healthy Boost License. I/WE specifically authorize Healthy Boost to obtain credit reports from one or more credit bureaus and background check on ME/US and MY/OUR business(es). A copy of this authorization may be used in place of and shall be valid as the original. I/WE understand that this application is considered active for 180 days from the date below. By submitting this application I/WE agree that this information is correct and I/WE give Healthy Boost, Inc., permission to obtain a Credit Report and Background Report for the individuals listed on this application. I understand and acknowledge that if I am married but do not provide complete information for myself and my spouse, Healthy Boost, Inc. cannot process this application.