Prospective Purchaser Fact Finder

In order for us to assist you in finding the right practice opportunity, we need to know you well enough to best assist you in purchasing a dental practice. Please complete this fact finder as thoroughly as possible. If you have a resume, you need only to supply us with the information that does not appear on your resume. Please be reminded that all responses will be kept confidential and this information will only be shared with the proposed Seller.

Name:

E-mail Address:

Where do you prefer to be contacted?
(Please complete the appropriate information below)

Home Office

Home Address

Office Address

Mailing Address:

City:

State:

Zip Code:

Phone:

Fax:

Cell Phone:

Best time to call:

a.m. p.m.

Confidential?

Yes No

Personal Data

Age:

Marital Status:

Number of Children & Ages:

Is spouse working?

Yes No

If Yes, in what field?

Are there any judgements pending against you or any of your business interests?

Yes No

If so, please explain:

Have you ever declared bankruptcy?

Yes No

Are you a US citizen?

Yes No

If No, please describe your immigration status:

Professional Education

Degree:

Date Rec'd:

School:

Degree:

Date Rec'd:

School:

Specialty Training:

Date Rec'd:

Specialty Training:

Date Rec'd:

Residency Training:

Date Rec'd:

Regional Boards:

Date Rec'd:

Work Experience

Associate

No. of years:

Practice Owner

No. of years:

Other

No. of years:

Average Monthly Production (last 12 months):

($)

Length of Transition Period you desire:

License Number:

State:

Date:

License Number:

State:

Date:

Has the State Board of Dentistry ever brought any action against you?

Yes No

If so, please explain:

Ideal Practice Goals

Geographic areas of interest:

Size (gross receipts) of practice:

($)

Number of operatories:

Price Range:

($)

Would you relocate if practice meets your other requirements?

Yes No

How did you hear about us?

	Web Search
	Consulting Firm
	Journal Ad
	Accountant
	Snyder Group Client
	Dental Supply Company
	Seminar
	Other