Confidentiality Agreement - Shea Practice Transitions

CONFIDENTIALITY AGREEMENT Please complete this two-part Confidentiality Agreement/Buyer Questionnaire if you are interested in having Shea Practice Transitions assist you with your practice transition. CONFIDENTIALITY AGREEMENT AND REPRESENTATION DISCLOSURE ("Agreement")
This Agreement is made on this date:
Date*
MM slash DD slash YYYY
by Shea Practice Transitions, P.A., a Minnesota Corporation, with its place of business at 6750 France Avenue South, Suite #114, Edina, Minnesota ("SPT"), clients of SPT ("SPT Clients"), and
Name*
First Name (required) Last Name (required) D.D.S. or D.M.D. (required)
, who has an interest in purchasing, buying into, or associating with a dental practice ("Buyer"). SPT and SPT Clients possess confidential and/or proprietary information related to a dental practice that Buyer has shown an interest in, including without limitation financial information, statements, books, records, and patient information, identity and location of SPT Client's dental practice, which may be articulated orally or in writing ("Confidential Information"). SPT wishes to disclose such Confidential Information to Buyer, and Buyer wishes to receive such Confidential Information in order to facilitate discussions regarding a possible business transaction involving Buyer. In consideration of the receipt of certain Confidential Information and the mutual promises made herein, the parties agree as follows:

1. Buyer's Duty to Protect Confidential Information. Buyer shall not disclose the Confidential Information to any third party other than attorneys and accountants whom are representing Buyer under professional privilege, without SPT and SPT Client's prior written permission. Buyer agrees to keep and protect with strict confidentiality, the Confidential Information and to prevent its unauthorized use or dissemination, except as authorized herein.

2. Buyer's Use of Confidential Information. All Confidential Information remains the property of SPT or SPT Clients and no licenses or other rights are granted or implied by this Agreement. Upon request by SPT or SPT Clients, termination or expiration of this Agreement, and at SPT's sole discretion, Buyer shall return all Confidential Information to SPT or SPT Clients and/or certify that all copies have been destroyed.

3. Term. This Agreement shall become effective as of the date first set forth above and shall terminate upon the earlier of (i) written notice of either party of its election, with or without cause, to terminate this Agreement; or (ii) three (3) years following the effective date.

4. Duration of Duty. Buyer's duty to protect Confidential Information disclosed under this Agreement remains even after the expiration as further provided herein.

5. Remedies. Buyer agrees and acknowledges that any unauthorized use of Confidential Information in violation of this Agreement will cause SPT or SPT Clients irreparable injury for which either may not have any adequate remedy at law. SPT and/or SPT Clients shall therefore be entitled to immediate injunctive relief prohibiting any violation of this Agreement, in addition to any other remedies that may be available (to either SPT and/or SPT Clients) in law or equity, including but not limited to damages, costs, attorneys fees and costs of litigation.

6. No Agency or Partnership. The parties do not intend that this Agreement creates any agency or partnership between them.

7. Modification. All additions or modifications to this Agreement must be made in writing and must be signed by all Parties.

8. Governing Law. This Agreement is made under and shall be construed according to the laws of the State of Minnesota.

9. Disclosure of Representation. Shea Practice Transitions, P.A. is representing its Client(s) only. Neither Ryan Brengman, Kevin Shea, nor Shea Practice Transitions, P.A. has undertaken or will undertake to represent Buyer as a broker, as Buyer's attorney for a transaction contemplated herein, or otherwise. Buyer is encouraged to seek Buyers own professional assistance, including legal representation, for any transaction contemplated by this Agreement. This Agreement may be executed in two or more counterparts, each of which shall be deemed an original for all purposes, and together shall constitute one and the same document. Buyer's facsimile or electronic signature shall be deemed an original signature.

SPT: Ryan Brengman, President

BUYER: (By entering your full name and D.D.S. or D.M.D. into this text field and pressing submit, you acknowledge entering this agreement)
Full Name*

BUYER'S QUESTIONNAIRE, PART 1

Contact Info
Name*
First Last Suffix
Title
DDS, DMD, or....
Birthdate
MM slash DD slash YYYY
Email*
Can we correspond with you at this email address?*
- Yes
- No
Where would you prefer to be contacted?*
- Home
- Office
- Other
What is your preferred method of contact?*
- Email
- Home Phone
- Office Phone
- Cell Phone

Home Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Can we correspond with you at this address and phone?*
- Yes
- No
Cell Phone

Office Address*
Street Address Address Line 2 City State ZIP Code
Office Phone
Can we correspond with you at this address and phone?*
- Yes
- No
Fax Number, if applicable

BACKGROUND INFO
Graduation Year*
Dental School*
Dental License Number*
State Issued*
Do you have a current CV or resume?*
- Yes
- No
If so, please upload the file
Max. file size: 256 MB.
Have any disciplinary actions been filed against you by any state licensing authority (e.g.; Board of Dentistry)?*
- Yes
- No
If so, please specify the date and circumstances:

Practice Info
What are you looking for?*
CTRL + Click to select more than one
Practice Types of Interest*
Clinically, what procedures are you proficient in?*
- Endo
- Ortho
- Implants
- Rotary Endo
- Pedo
- Perio
- Cosmetic Surgery
- Oral Surgery
- TMJ
Areas of Dentistry you enjoy?*
Briefly describe your ideal practice*
Region Desired
Ctl + click to select more than one region
What is your preferred location?*
Please be descriptive about what you are looking for and why.
Income Expectations
What is the nature of the practice you would like to find (e.g. amalgam-free, all fee-for-service production, associate buy-in, solo practice sale, buy-out)?

What is your timeframe to own a practice?
Is there anyone else that will be assisting you with your decision (e.g. spouse, family member consultant, accountant, attorney)? If so, please specify.
Have you had an opportunity to look at other practices?
Other opportunities explanation
What did you like or dislike about other practices you have seen?
Have you talked to other brokers? If so please specify.
What did you like or dislike about other brokers?

References
Please list at least two Dental Labs whom have performed work for you
Please include lab name, telephone number and lab tech or contact person):
Please list at least two references whom we can contact
Please include name , email and telephone number

Professional Advisors
Advisor Type 1
Advisor's Name 1
Advisor's Email 1
Advisor Type 2
Advisor's Name 2
Advisor's Email 2

By checking this box, I certify that the foregoing information is true and accurate to the best knowledge. I hereby authorize and consent to contacting the references listed above (required).*
- I agree
CAPTCHA
Hidden
Lead Type
Hidden
Industry Type

BUYER'S QUESTIONNAIRE, PART 1

Contact Info

BACKGROUND INFO

Practice Info

References

Professional Advisors