BUYER INFORMATION FORM

Please print form, fill out completely and send to us.

Name: _________________________________________________________________________

Address: _________________________________________________________________________          

City: ______________________________      State: ____________    Zip: ______________

Business Phone: _____________________        Cell Phone: _________________________

Home Phone:  ________________________      Fax: _______________________________

Best Time to Call: _____________________       Email:_____________________________

In what geographical area would you like to practice?  Please circle all that apply.

Manhattan         Brooklyn           Bronx               Queens             Staten Island

Nassau             Suffolk              Westchester       Other                New Jersey        Rockland County

Please circle which type of practice you are interested in.

Insurance practice             Private practice              Capitation         Medicaid

Please circle which category of practice you are interested in. 

0-$500,000                    $500,000-$1million                     $1million or above