Dental Confidentiality Form

HOW DID YOU HEAR ABOUT US (Seminar, Convention, Website, Agent, Etc.):

ENTER FULL NAME:

COMPANY: 

ENTER MAILING ADDRESS:   ( Home:           Office:      )

CITY: 

STATE:       ZIP CODE:   -  

HOME PHONE:  ()    -  

CELL PHONE:  ()    -  

OFFICE PHONE:  ()    -  

EMAIL ADDRESS:  

BUYER OR SELLER:                   

AREA OF INTEREST: (Exp. Counties, Cities)

Below is our Confidentiality Form.  Incase you decide to purchase a practice at some point, this is to protect the privacy of the Selling Doctors.  We cannot give out any information without this form.  Thank You.

CONFIDENTIALITY NON - DISCLOSURE FORM

Acknowledgement, Agreement and Record of Showing ALL PRACTICES LISTED OR INTRODUCED TO BY DOCTOR'S CHOICE COMPANIES, INC. Business Name: Doctor's Choice Companies, Inc. J. Kenny Jones / President - Broker Brokers Initials: JKJ I the undersigned prospective purchaser (s) hereby acknowledge receipt of confidential information about the business here described, introduced to me by Doctor's Choice Companies, Inc. (Exclusive Broker and Procurring Broker) Please, do not contact owner, employees, suppliers or other brokers. In consideration of your having provided the Confidential information, I hereby agree, (1) not to reproduce or divulge such information to any person without owner's written consent. (2) I understand that disclosure to any other person's of the availability of the practice may cause great harm to the seller. (3) To conduct all further inquiries into the above opportunities exclusively through the office of the above named Broker, to maintain such Confidentiality. (4) To NOT contact the seller or enter the sellers practice without permission idrectly from the seller. I understand that the Broker has entered into a listing agreement or contract with the owner or their authorized agent to represent the above listed Business which provides for commission payment to Broker from Seller. Buyer agrees to indemnify and hold harmless Broker and those relying thereupon for damages resulting from the inaccuracy of said information and from Seller's failure to disclose any facts materially affecting the value or desirability of the property and Business.

Below is our Transaction Broker Notice Form.  Incase you decide to purchase a practice at some point, this is to protect the listing Broker.  We cannot give out any information without this form.  Thank You.

TRANSACTION BROKER NOTICE

Florida Real Estate Licensees who desire to operate as a Transaction Broker are required by Section 475.25(1)(q) 3, Florida Statutes, to give written notice to all parties to the real estate transaction. The purpose of the TRANSACTION BROKER NOTICE is to place the parties on notice that the licensee will be operating as a Transaction Broker and to describe the licensee's role as a Transaction Broker. A licensee who facilitates a brokerage transaction between a Seller and a Buyer without representing either party as an agent known as a Transaction Broker. A Transaction Broker has no fiduciary duty to either party except the duties of accounting and to use skill, care and diligence. A Transaction Broker is REQUIRED to treat the seller and buyer with honesty and fairness, and shall disclose all known facts materially affecting the value of the property to the Seller and Buyer. The TRANSACTION BROKER NOTICE has been adopted by the Florida Real Estate Commission and is required by Rule 61 J2-10.037 of the rules of the commission. BPR 70-01-001.025

Date:    Enter Today's Date (exp. mm/dd/yy)

By Entering your First and Last Name You are agreeing to the above,

 CONFIDENTIALITY NON-DISCLOSURE FORM and the

TRANSACTION BROKER NOTICE: