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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

Owner's Name *
Owner's Name
Phone *
Phone
Cell Phone *
Cell Phone
How many and what kind, chains, independents, distance from store
Pharmacists, technicians, other, any specialty personnel (surgical fitters, etc.)
For the past three years, gross and net margins if available
Daily Rx count - weekdays and weekends, Rx breakdown, third party vs. cash
Rx vs. OTC, any special categories, surgicals, cards and gifts, etc
Do not add commas
$
Date of most Recent Phyiscal Inventory Taken
Date of most Recent Phyiscal Inventory Taken
Buy-SellaPharmacy NDA *
You must read and acknowledge our NDA at the bottom of this form.