Associate Placement

Submission Form

Fill out the form below. If you have a resume, please email it to info@doctors-choice.com.

Disclaimer: Any tax or legal advice contained from Doctor’s Choice is not intended and cannot be used by any individual, entity or organization in regard to any tax or legal matter whatsoever, more particularly, to avoid any tax penalties. To be extent any tax, legal, professional or business advise contained from Doctor’s Choice may support the marketing or promotion of the transaction or matters included from Doctors choice. every individual. entity or organization should seek competent tax or legal advice.

How Did You Hear About Us?

If Other, Where?

Contact Information

Full Name

Home Phone

Cell Phone

Office Phone

Email Address

Which is the Best Way for a Doctor to Contact you?

Location Information

Street Address

Home or Office Address?

City

State

Zip Code

Background Information

What School did you Graduate From?

What Year did you Graduate?

What area are you interested in working? (Area meaning 'Location, County, City'. Use Commas to Separate.)

How many miles from home do you wish to travel? (Include 'Miles')

Choose Region (All that apply) in which you're willing to work.

Are you a DMD or DDS?

Are you left or right handed?

Are you a Specialist or General Dentist?

Date when you're available to work?

Full-time, Part-time or Either?

Will You accept Temporary Work?

Are you willing to relocate?

License Information

Enter your License Number (If lic # is pending, put PENDING)

Gender

Which are you looking for?

Do you have a Medicaid License?

If Yes, What is your Medicaid License number?

Is your Medicaid License number Active?

Additional Comments (Please write anything that you would like your employer to know about you, your work history, whether you're looking for an Associateship, and / or Buy-In, etc.) No names, Addresses or Phone Numbers Please

Enter Today's Date (mm/dd/yy)

CONFIDENTIALITY NON-DISCLOSURE FORM Acknowledgment, Agreement and Record of Showing ALL PRACTICES LISTED OR INTRODUCED TO BY DOCTORS CHOICE COMPANIES, INC. Doctor's Choice Companies, Inc. (Transaction Broker) J Kenny Jones/President-Broker 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. Transaction Broker. Please, do not contact owner, employees, suppliers or other brokers. (Staff is not aware of Sellers plans) In consideration of your having provided the above 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 directly 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. Prospective 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. Buyer acknowledges Doctors Choice Companies, Inc. as the procuring Broker, should buyer ultimately purchase any practices introduced to by buyer to Broker. Memo: Please do NOT contact Seller or enter the office without a pre-arranged appointment. Staff members are NOT aware of the Sellers intentions. TRANSACTION BROKER NOTICE As required by Florida Statue 475 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 licensees 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

By Entering your First and Last name, you are agreeing to the above, Transaction Broker Notice and Confidentiality Non-Disclosure Forms

No private health information should be sent through this form. Please enter your information and we'll contact you directly.