seller registration

Please make every effort to complete all sections of this registration form. The more comprehensive the information we receive, the more effective we can be in helping you find the right buyer for your pharmacy. When you click "accept" you will be indicating that you accept the terms of our nondisclosure agreement. If you prefer to provide this information by fax, you can print the form and fax it to 801-751-5685, a secure, private fax number.

*indicates required field

Store Name

Owner's Name

First Name

Last Name

Store Address

City

State

Zip

Phone

(###)

###

####

Cell Phone

(###)

###

####

Email Address

Type of Location

State Location

Competitors

How many and what kind, chains, independents, distance from store

Store Hours

Store Size | Selling Area | Storage Areas

Staff

Pharmacists, technicians, other, any specialty personnel (surgical fitters, etc.)

Sales Volume

For the past three years, gross and net margins if available

Prescription Volume

Daily Rx count - weekdays and weekends, Rx breakdown, third party vs. cash

Sales Mix

Rx vs. OTC, any special categories, surgicals, cards and gifts, etc

Value of Inventory

Do not add commas

Date of most Recent Phyiscal Inventory Taken

YYYY

Reason for Proposed Sale

Desired Timing

Best Method/Location for Contacting you

Buy-SellaPharmacy NDA

You must read and acknowledge our NDA at the bottom of this form.

I have read and agree to the NDA

I have read and do not agree to the NDA

READ OUR OUR NDA

SALES HISTORY

REFERENCES