Application Step 1 of 19 - Getting Started 0% HiddenListing ID Please email us the following: Previous 3 years of corporate tax returns HiddenFile Drop files here or Select files Max. file size: 100 MB, Max. files: 3. YTD P&L (CPA generated if possible) Hidden Drop files here or Select files Max. file size: 100 MB, Max. files: 1. Payroll Summary Report (previous 3 years and YTD) Hidden Drop files here or Select files Max. file size: 100 MB, Max. files: 4. Name* First Last Date of Birth* MM slash DD slash YYYY Home Street Address* City* State*SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip* Degree*Select Degree...NAMDDDSDMDDental School Alma Mater* Year Graduated* Right or Left handed?*SelectRightLeftAmbidextrous Practice Trade Name* GP or Specialty*Select GP or Specialty...NAGeneral PracticeOrthodontic PracticeOral Surgery PracticePeriodontal PracticeProsthodontistEndodontistPediatricIncorporated?*SelectNAYesNoCorporation Suffix*Please SelectNASPGPLPLLPLLLPLLCPLLCOtherCorporation Type*Please SelectNACSWeb Address* Practice Street Address* Practice City* Practice County/ Parish* Practice State*VirginiaPractice Zip Code* Practice Phone*Practice Fax Number*Accountant/ Company* Accountant Phone*Accountant Fax*Accountant Email* Attorney/ Law Firm* Attorney Phone*Attorney Fax*Attorney Email* How was practice started?*SelectNAPurchaseStartupYear Beginning Practice in Current Location* Purchased from* In what year?* Associate(s)?*SelectNA012345678910+Partner(s)?*SelectNA012345678910+Do you share space?*SelectNAYesNoNot AvailableHas an associate or partner left your practice in the last 2 years?*SelectNAYesNoNot AvailableWhen?SelectNAJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberIs there an assignable restrictive covenant?*SelectNAYesNoNot AvailablePlease Describe Is there an assignable restrictive covenant?*SelectNAYesNoPlease DescribeIs there an assignable written agreement?*SelectNAYesNoPlease DescribeIs there a buy-out agreement?*SelectNAYesNoPlease DescribeDescribe any internal marketing*Describe any external marketing* Office sq. ft.* Expandable sq. ft.* Is Office Handicapped Accessible?*SelectNAYesNoNumber of Parking Spaces*Number of Equipped Operatories*Number of Operatories Used Primarily by Hygienists*Number of Operatories Used Primarily by Dentists*Number of Unplumbed and Empty Operatories*Number of Plumbed but Unequipped Operatories*Do you or your entity own the building?*SelectNAYesNoReal Estate InformationDo you want to sell the building?*SelectNAYesNoLegal Name of Owner* Annual Property Taxes*Annual Property Insurance*Was the building appraised?*SelectNAYesNoWhen was the appraisal?*SelectNAJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat is the appraised amount or estimated value?*Lease InformationLease Start Date* MM slash DD slash YYYY Lease End Date* MM slash DD slash YYYY Monthly Rental Amount*Is there an option to purchase?*NAYesNoDescribe Lease renewal/ Purchase options* Number of days per week you currently work*What is your ideal post-sale scenario?*Do you plan to work operative post-sale?*NAYesNo Enter the number of days per week you wish to work for the buyer after the sale: In the first year*In the second year*In the third year* Has the practice been appraised?*NAYesNoWhen was the appraisal?*SelectNAJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat was the appraised amount?*Have you previously tried to sell your practice?*NAYesNoWhen?* MM slash DD slash YYYY Did you use a broker?*NAYesNoWho was the previous broker?* Is your practice currently listed with another broker?*NAYesNoWho is your current broker?* Has your practice gross changed significantly?*NAYesNoPlease explain the change in gross* Did you provide the following? Nitrious Oxide*NAYesNoCounscious Sedation or DOCS*NAYesNoIV Sedation*NAYesNoMercury Free*NAYesNoHow many different patients have you treated in the last 18 months?*How many new patients per month?*Average number of patients treated per day by dentists?*Average number of patients treated per day by hygienists?*% of practice income from cash? (Fee for Service)*% of practice income from Preferred Provider Insurance (PPO)*How many plans are you enrolled in? (PPO)*% of practice income from Non-referred Provider Insurance?*% of practice income from Capitation?*How many plans are you enrolled in? (Cap)*% of practice income from Medicaid?*How many plans are you enrolled in? (Med)* To change number of plans, go to previous page (Practice B) and adjust number of plans. Preferred Provider Plans % of Normal Fee No Plans Capitation Plans % of Normal Fee No Plans Medicaid Plans % of Normal Fee No Plans Mon Closed Monday __________Open__________ : Hours Minutes AM PM AM/PM _______Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM Tues Closed Tuesday __________Open__________ : Hours Minutes AM PM AM/PM _______Lunch_______Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM Wed Closed Wednesday __________Open__________ : Hours Minutes AM PM AM/PM _______Lunch_______Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM Thurs Closed Thursday __________Open__________ : Hours Minutes AM PM AM/PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM Fri Closed Friday __________Open__________ : Hours Minutes AM PM AM/PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM Sat Closed Saturday __________Open__________ : Hours Minutes AM PM AM/PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM Sun Closed Sunday __________Open__________ : Hours Minutes AM PM AM/PM ________Lunch________Select30 Min1 Hour1.5 Hrs2 HrsOther__________Close__________ : Hours Minutes AM PM AM/PM What type of recall system do you use?* What type of practice management software do you use?* Major Employers in the area: Describe any major economic changes in your drawing area.* Please use this section to list all direct employees and contractors. Do not include contracted services (such as janitorial, maintenance, equipment and tool cleaning services, etc). Please click the ㊉ symbol to add row. Employees*PostitionYear HiredExpected to stay?Annual Value of BenefitsHourly Rate% of CollectionsIs this employee family? Please click the ㊉ symbol to add row. Benefits*What benefits do you provide to the employees?What is the total cost of these benefits to the practice annually? Does practice meet OSHA standards?*NAYesNoIf not, why?Does practice meet HIPAA standards?*NAYesNoIf not, why?Have you had any practice-related lawsuits filed against you in the past seven years?*NAYesNoIf yes, why?Have your received any disciplinary actions in the past seven years?*NAYesNoIf yes, why?Are there any health problems that could affect your practice of dentistry?*NAYesNoIf yes, why?Do you forgive any insurance co-payments?*NAYesNoApproximately what % of your collections is forgiven?If yes, why? Annual Insurance Expense Annual Owner Health Insurance:*Annual Staff Health Insurance:*Annual Owner Life Insurance:*Annual Malpractice Insurance:*Annual Owner Personal Benefits (disability, etc...):*Total Annual Expense for Insurance:* Annual Tax Expense Annual Staff Payroll Tax:*Annual Owner Payroll Tax:* Total Annual Payroll Tax:*Annual Ad Valorem/ Property Taxes:*Annual Real Estate Taxes:*Total Annual Expenses for Taxes:* Total Annual Pension Expense Annual Staff Pension Expense:*Annual Owner Pension Expense:*Total Annual Expenses for Pension:* Practice and PhilosophyPlease describe your practice, staff, patients, community, and practice philosophy.* Click (+) to add more items in each category.Dental Chair(s)MakeModelApproximate Age (Years)Quantity Dental Unit(s)MakeModelApproximate Age (Years)Quantity Dental Light(s)MakeModelApproximate Age (Years)Quantity Dental X-Ray Sensor(s)MakeModelApproximate Age (Years)Quantity CAD/CAM(s)MakeModelApproximate Age (Years)Quantity Panoramic X-Ray(s)MakeModelApproximate Age (Years)Quantity Scanner(s)MakeModelApproximate Age (Years)Quantity New Technology PurchasesMakeModelApproximate Age (Years)Quantity CommentsThis field is for validation purposes and should be left unchanged.
