Non-Disclosure Agreement
PS Broker
LISTING CODE
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Signature
*
Your Name
*
Email
*
Phone Number
*
Format: (000) 000-0000.
Mailing Address
*
Company Name (If Applicable)
Have you submitted an NDA to PS Broker within the past year?
*
Yes
No
Yes, but my information/preferences have changed.
Are you a DVM?
*
Please Select
Yes
No
Vet Student
Spouse is a DVM
Son/Daughter is a DVM
Representing a DVM
What is your veterinary license number?
*
Enter 'none' if you are not a DVM.
What year did you graduate from veterinary school?
*
Enter 'none' if you are not a DVM.
Do you currently own a veterinary practice?
*
Please Select
Yes
No
Are you pre-approved for financing to purchase?
*
Please Select
Yes
No
In the Process
Need Financing
Cash Buyer
What is your preferred seller transition period?
*
Please Select
1-3 Months
3-6 Months
6-12 Months
> 1 Year
> 2 Years
No Preference
What is your preferred practice revenue size?
*
Please Select
< $500K
$500K - $1M
$1M - $1.5M
$1.5M - $2M
$2M - $2.5M
$2.5M - $3M
$3M - $3.5M
$3.5M - $4M
> $4M
No Preference
What type of practice are you interested in?
*
Small Animal
Large Animal
Mixed Animal
Feline
Equine
Emergency
Other
Hold 'ctrl' to multi-select.
What states are you interested in?
*
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Hold 'ctrl' to multi-select.
Background Information (Check All That Apply)
*
I have filed for bankruptcy within the last 7 years.
I have defaulted on an SBA loan.
I have faced disciplinary action by an authoritative body.
I have been convicted of or pled guilty to a felony that hasn't been sealed or expunged.
NONE of the background statements apply to me.
How did you hear about us?
*
Please Select
Search Engine
Digital Ad
Classified Ad
Online Marketplace
Social Media
Vet Conference
Referral
Lender
Direct Mail
Other
Additional comments or requests...
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