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Confidentiality Agreement
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Is this your first time contacting us?
(Required)
Yes
No
How did you find out about us?
(Required)
Referral
Chiropractic School
PBI Website
Mailer
Internet Search
Event
Advertisement (online)
Other
Geographically, what is your preference for size of community?
(Required)
1,000-25,000 (small town)
25,001- 49,999 (mid-size)
Over 50,000 (metro)
What chiropractic techniques do you utilize?
(Required)
Diversified
Thompson
Activator
CBP
Gonstead
Functional Medicine
SOT
AK
Flexion/Distraction
Palmer Pkg
Other
What special interests do you have?
(Required)
Sports
Rehab
Nutrition
Pediatrics/ Pregnancy
Family Practice
What is your experience level?
(Required)
Student
Licensed 0-2 years
Licensed more than 2 years
How much available capital do you have access to?
(Required)
$1,000-$10,000k
$10,000-$50,000k
Over $50,000k
What state(s) are you licensed in?
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Where would you like to practice? (city, state)
(Required)
Is there anything else you would like our broker to know before the appointment?
AGREEMENT AND ACKNOWLEDGEMENT OF CONFIDENTIALITY AND LIABILITY FOR UNAUTHORIZED DISTRIBUTION
I hereby acknowledge and agree that all of the information I receive, whether electronic, written or oral, associated with practices listed with Practice Brokers, Inc., is strictly confidential and cannot be distributed by any means or in any manner, to any person or entity, whatsoever, without the express written authority of the selling doctor and Practice Brokers, Inc.
I understand that distribution, by whatever means, without first obtaining proper written authority, may be unlawful and that as a result, the selling doctor and Practice Brokers, Inc., may pursue any and all legal claims and actions against me or my agents in a court of competent jurisdiction. I hereby agree that as a condition of obtaining this information from Practice Brokers, Inc., I will not permit, authorize, allow or participate in any way, in the distribution of any of the confidential information pertaining to the selling doctor without first obtaining proper written authorization from Practice Brokers, Inc.
THIS FORM MUST BE DATED, SIGNED AND RETURNED TO PRACTICE BROKERS, INC. PRIOR TO THE DISTRIBUTION OF INFORMATION. NO ADDITIONAL INFORMATION REGARDING ANY PRACTICE WILL BE PROVIDED UNTIL THIS DOCUMENT IS SIGNED AND ON FILE AT PRACTICE BROKERS, INC.
The parties to this Agreement acknowledge that for all purpose relating to this document, electronic signatures shall be deemed the equivalent of original signatures.
Agreement
(Required)
I agree to the confidentiality agreement as listed above.
Signature
(Required)