PROFESSIONAL PRACTICE SPECIALISTS, INC.
CONFIDENTIAL BUYER'S QUESTIONNAIRE
Please print form, complete & sign, then return by fax or mail.
PROFESSION: -CHIROPRACTIC- -DENTAL- -ACUPUNCTURE- (Please circle one)
Name: ____________________________________ Birthdate: _______________
Spouse's Name: ____________________________________
Address: _______________________________________________________________________________________ ________________________________________________________________________________________________
City, State, Zip: ________________________________________________________________
TELEPHONE: RESIDENCE _____________________
OFFICE _____________________
FAX _____________________ MOBILE _____________________
E-MAIL:_____________________________Can you receive attachments?
YES___ NO___
PROFESSIONAL EXPERIENCE: (Please include
date of graduation, including name of school, post-graduate education,
employment history, private practice experience, etc.) ___________________________________________________________________________________________
___________________________________________________________________________________________
TYPE OF PRACTICE DESIRED:
CHIRO (Adjustive Techniques Used)__________________________________________
DENTAL (Specialty)_________________________________________________________
ACUPUNCTURE (Specialty)_________________________________________________________
GEOGRAPHIC AREA DESIRED:___________________________________________________
ARE YOU A U.S. CITIZEN? IF NOT, IS YOUR SPOUSE ?____________________________________________________
WHAT STATE(S) DO YOU HOLD A LICENSE?_______________________________________
SIZE OF PRACTICE DESIRED (annual gross): $__________________________________
MINIMUM NET INCOME DESIRED (annual): $______________________________________
WHEN ARE YOU AVAILABLE TO ASSUME THE PRACTICE? _____________________________
AMOUNT AVAILABLE FOR DOWN PAYMENT? $_______________________________________
HOW IS YOUR CREDIT? -FLAWLESS- -GOOD- -FAIR- -POOR- -BANKRUPTCY- (Circle one) Excellent credit is a big plus toward obtaining 100% financing. It would be to your advantage to check your credit and clear up any errors or problems. Credit reports (about $8.50) can be obtained from EQUIFAX @ 800-685-1111; EXPERIAN @ 800-682-7654; or TRANSUNION @ 800-916-8800. If you have been denied credit, employment, or insurance within the past 60 days, you may get a complimentary credit report from Experian @ 888-682-7654. Please obtain your credit score from Equifax or Experian. SCORE______
DO YOU HAVE THE PREVIOUS THREE (3) YEARS TAX RETURNS THAT YOU COULD PROVIDE TO A FUNDING SOURCE?
HOW DID YOU FIND OUT ABOUT PROFESSIONAL
PRACTICE SPECIALISTS, INC.?
___________________________________________________________________________________________
CONFIDENTIALITY
AGREEMENT
I, _____________________________
acknowledge and agree that the information I receive from Professional
Practice Specialists, Inc. (PPS), is confidential to PPS and the clients
PPS represents. I will not disseminate or disclose any of the information
obtained from PPS or PPS’s clients without the prior written consent
of PPS. I agree not to contact any seller, referral source, staff or
associate represented by PPS without the consent of PPS. I agree not
to mention the name of the seller or clinic or the name of the lender
to anyone other than my family, attorney, accountant, insurance person
or finance person without the consent of PPS.
AGENCY
DISCLOSURE
I understand
that Professional Practice Specialists, Inc. is the agent of the seller
exclusively and that they are obligated to honest dealing and disclosure
of material facts to both parties. Additionally the seller’s agent
has the fiduciary duties of loyalty, confidentiality, obedience, reasonable
care and diligence, and accounting in dealings with the seller.
_____________________________________________Date________________________
Buyer’s
Signature
PROFESSIONAL PRACTICE SPECIALISTS,
INC.
18880 N.W.
Nelscott Street, Portland, OR 97229
|
Portland (503) 645-7590 |
Nationwide (800) 645-7590 FAX (503) 961-8787