Untitled Document


Registration
Personal Information	In order to submit this form you must enter information in all the fields.
FIRST NAME:	____________________________________________________ INITIAL:________________
LAST NAME:	___________________________________________________________________________
TITLE:	DMD DDS STUDENT
ADDRESS:	___________________________________________________________________________
CITY:	___________________________________________________________________________
STATE:	____________________________________________________ ZIP: ___________________
EMAIL:	___________________________________________________________________________
HOME PHONE:	__________ - __________ - __________

Education
DENTAL DEGREE:	___________________________________________________________________________
DATE RECEIVED:	__________ / __________ / __________
SCHOOL:	___________________________________________________________________________
SPECIALTY TRAINING:	___________________________________________________________________________
DATE COMPLETED:	__________ / __________ / __________
SCHOOL:	___________________________________________________________________________
LICENSE NUMBER:	____________________________________________________ STATE: ________________

Professional Information
OFFICE LOCATION:	___________________________________________________________________________
CITY:	___________________________________________________________________________
STATE:	____________________________________________________ ZIP: ___________________
OFFICE PHONE:	__________ - __________ - __________
FAX:	__________ - __________ - __________

State Or Regional Boards That You Have Passed
STATE/REG 1:	___________________________________________________________________________
DATE:	__________ / __________ / __________
STATE/REG 2:	___________________________________________________________________________
DATE:	__________ / __________ / __________
STATE/REG 3:	___________________________________________________________________________
DATE:	__________ / __________ / __________

Dental Practise Experience

ASSOCIATE*	NUMBER OF YEARS	_______________________________________
PRACTISE OWNER*	NUMBER OF YEARS	_______________________________________
OTHER*	NUMBER OF YEARS	_______________________________________

Please answer the following:
	1) Average monthly practice production that you have consistently achieved in the past?
	___________________________________________________________________________ ___________________________________________________________________________
	2) For how long of a transition period would you desire a Seller to remain involved in practice?
	___________________________________________________________________________ ___________________________________________________________________________
	3) Are there any unsatisfied judgements against you or any businesses that you have owned?
	___________________________________________________________________________ ___________________________________________________________________________
	4) If you were to purchase a practice, where would you obtain the money required for a down payment?
	___________________________________________________________________________ ___________________________________________________________________________
	5) What is the maximun amount of money you could obtain for a down payment?
	___________________________________________________________________________ ___________________________________________________________________________

6) What type of practice are you looking for?

GENERAL		PERIODONTIC		ENDODONTIC
ORTHODONTIC		PEDIATRIC		ORAL SURGERY

7) In what geographical area are you willing to practice?

___________________________________________________________________________
___________________________________________________________________________

8) Are you left or right handed? RIGHT LEFT

Clinical References
1)	NAME:	___________________________________________________________________________
ADDRESS:		___________________________________________________________________________
CITY:		___________________________________________________________________________
STATE:		____________________________________________________ ZIP: ___________________
CONTACT:		YES NO

2)	NAME:	___________________________________________________________________________
ADDRESS:		___________________________________________________________________________
CITY:		___________________________________________________________________________
STATE:		____________________________________________________ ZIP: ___________________
CONTACT:		YES NO

3)	NAME:	___________________________________________________________________________
ADDRESS:		___________________________________________________________________________
CITY:		___________________________________________________________________________
STATE:		____________________________________________________ ZIP: ___________________
CONTACT:		YES NO

Personal References
1)	NAME:	___________________________________________________________________________
ADDRESS:		___________________________________________________________________________
CITY:		___________________________________________________________________________
STATE:		____________________________________________________ ZIP: ___________________
CONTACT:		YES NO

2)	NAME:	___________________________________________________________________________
ADDRESS:		___________________________________________________________________________
CITY:		___________________________________________________________________________
STATE:		____________________________________________________ ZIP: ___________________
CONTACT:		YES NO

3)	NAME:	___________________________________________________________________________
ADDRESS:		___________________________________________________________________________
CITY:		___________________________________________________________________________
STATE:		____________________________________________________ ZIP: ___________________
CONTACT:		YES NO

Financial Reference
NAME:	___________________________________________________________________________
ADDRESS:	___________________________________________________________________________
CITY:	___________________________________________________________________________
STATE:	____________________________________________________ ZIP: ___________________
CONTACT:	YES NO