800-988-5674

The Snyder Group
100 Centre Boulevard
Henry Schein PPT
Suite A
Marlton, NJ 08053
Phone - (856) 988-7588
Toll Free - (800) 988-5674
Fax - (856) 985-7428

Prospective Purchaser Fact Finder

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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:
Degree/Title:	Select Your Degree/Title CPA DDS DMD ESQ MR. MRS. Other		If Other Degree/Title:
Home Address
Mailing Address:
City:
State:			Zip Code:
Phone:			Fax:
Cell Phone:
Best time to call:	a.m. p.m.
Are there any judgements pending against you or any of your business interests?				Yes No
If Yes,what year?:
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):				($)
License Number:	State: Date:
License Number:	State: Date:
Has the State Board of Dentistry ever brought any action against you?				Yes No
If so, please explain:
	Ideal Practice Goals
Geographic areas of interest:
Size (gross receipts) of practice:				($)
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