Information Request Security*Click to SelectNo Security NecessaryKeep My Information SecureName* First Last Phone*Email* Services Needed?*Click to SelectPractice Sales: Information NeededPractice Buyer Information NeededResidential Purchase Information RequestedCommercial Purchase Information RequestedGeneral Information RequestPractice Sales: Information Needed:Agent Requested:Location:Which applies to you?First Time on the MarketPrevious attempt (in the year):Year:Type of PracticeGeneral PracticeSpecialtyDescribe Your SpecialtyIs there a lease in place?YesNoYears left on leaseLease payment amount per monthPaying month-to-month rent?YesNoType of buildingStreet Level EntryMulti-story level buildingNumber of storiesDoes your staff know you are planning to sell the practice?YesNoAge of Practice (Years)Reason for saleRetiringDownsizingOtherPractice Buyer Information Needed:Agent RequestedPractice Production: (Enter two amounts below)Practice producing collections of between $_________ and $___________ as verified by the practice software report. Area Search to Include Zip Codes (list all the apply) Area Search to Include City(s) (list all the apply) Purchase Paid by:CashBank LoanDo you need a plan & assistance in obtaining a loan?YesNoValuationRequire ValuationDue Diligence by:Due diligence by:Time of PurchasePurchase to be completed within 3 monthsPurchase to be completed within 6 monthsNeed to purchase a residence in the areaResidential Purchase Information RequestedAgent RequestedType of ResidenceHome with propertyCondominiumTownhousePrequalified loan?YesNoLoan prequalified with?Loan AmountCommercial Purchase Information RequestedAgent RequestedType of Property Industrial Medical Office 1031 Exchange Mixed Use Investment Owner User Pre-qualified for a loan amount of:Loan Needed?YesNoCan afford: (enter the amount you can afford)General InformationAgent RequestedRequesting Information Regarding:First ChoiceSecond ChoiceThird Choice
