Register As A Buyer

First Name:*

Last Name:*

Email:*

Date of Birth:

Are you a US Citizen? -- Yes No

What is your current INS status?

Mobile Phone Number:

Secondary Email:

If your Spouse will be the primary contact, please provide us with their information. Spouse's Full Name:

Spouse's Email:

Spouse's Mobile Phone:

What is your current career status? -- Student Resident/Graduate Student Associate/Employee Military Dentist Owner/Partner Other

How many years have you been in the above career status?

Dental School Attended:

Graduation Year:

Degree:

License Number:

Residency/Graduate School Attended:

Graduation Year:

Degree:

What practice types are you interested in? (Please check all that apply.)

What transition types are you interested in? (Please check all that apply.)

What is the ideal date for this transition?

What delivery system do you prefer? -- Right-handed Left-handed Interchangeable

What is the ideal number of operatories you want in the facility? -- Undecided 1 to 3 4 to 6 7 or More

What is the ideal amount of annual collections you want for the practice? -- Undecided Less than $400,000 $400,000 to $600,000 $600,000 to $800,000 $800,000 to $1 Million $1 Million to $1.2 Million $1.2 Million to $1.5 Million $1.5 Million or More

What is your desired annual income? -- Undecided Less than $100,000 $100,000 to $200,000 $200,000 to $300,000 $300,000 to $400,000 More than $400,000

What is your preference for patient payment type? -- Fee for Service PPO/Insurance Medicaid

Would you be willing and able to relocate? -- Yes No

What is the furthest commute you would consider?

What Regions are of most interest to you? (Please check all that apply.)

First:

Second:

Third:

Are you working with another broker? -- No Yes

What is the broker's name? If yes, what is the broker's name?

Which lenders have you already contacted about financing?

Do you have an accountant? -- No Yes

What is the accountant's name(s)?    If yes, what is the accountant's name(s)?

Do you have an attorney? -- No Yes

What is the attorney's name(s)? If yes, what is the attorney's name(s)?

Do you have an insurance agent for Life & Disability? -- No Yes

What is the insurance agent's name(s)?    If yes, what is the insurance agent's name(s)?

Do you require any reasonable accommodations in order to perform the essential functions of the position for which you are considering? -- No Yes

Explain: *

If Yes, please explain.

Do you currently have any infectious diseases that ethically you feel should be disclosed to potential patients? -- No Yes

Explain:* If Yes, please explain.

Have you been the subject of any disciplinary proceedings by the State Dental Board? -- No Yes

Explain: *

If Yes, please explain.

Are there any unsatisfied judgments against you or any business you have owned?
-- No Yes

Explain: *

If Yes, please explain.

Have you ever filed for bankruptcy?
-- No Yes

Explain:*

If Yes, please explain.

Malpractice Claim?
-- No Yes

Explain: *

If Yes, please explain.

Crime involving moral turpitude?
-- No Yes

Explain: *

If Yes, please explain.

Criminal or civil litigation involving substance abuse?
-- No Yes

Explain: *

If Yes, please explain.

Charge of Fraud or Tax-Avoidance with regard to any Federal or State taxes?
-- No Yes

Explain:*

If Yes, please explain.

Cash on hand and in banks

Marketable securities (stocks, bonds, non‐retirement funds)

Pension, 401k, IRA or other retirement funds

Full Legal Name: *

By checking this box, I agree that to the best of my knowledge, all of the information provided is accurate and correct. I also agree that such action is an electronic substitute for my signature on this form. I also acknowledge that the information provided in this form is intended to be and will be disclosed to persons (including corporations, partnerships, firms, lenders and other individuals) for the purposes contemplated and that PMA shall have no liability for any claims, demands or action arising in connection herewith.

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