STATEMENT OF:

CONFIDENTIALITY AND NON-DISCLOSURE

The UNDERSIGNED acknowledges requesting that Al Heaps & Associates Inc., furnish the UNDERSIGNED with certain confidential information relating to the business affairs and operations of professional practices, for whom Al Heaps & Associates Inc., is the agent, for the purpose of a possible purchase by the UNDERSIGNED of the said dental practice or for an interest therein.

The UNDERSIGNED agrees that the information and documents disclosed to him/her are private in nature and shall remain confidential.  The UNDERSIGNED further agrees that the disclosure of any information or documentation with respect to these professional practices would cause irreparable harm and damage to these practices and agrees that he will not disclose to any person, firm or corporation any information or documents, which the UNDERSIGNED shall require regarding these professional practices, except for his attorney or accountant, without the express written consent of the owner of that practice or practices.

The UNDERSIGNED agrees not to contact, in any way, any Seller/Client of Al Heaps & Associates Inc., without first obtaining express permission from Al Heaps & Associates Inc.  Also, the UNDERSIGNED agrees not to divulge to any employees of any Seller/Client of Al Heaps & Associates Inc., that the practice of any Seller/Client of Al Heaps & Associates Inc., is for sale, or any such other confidential information.

The UNDERSIGNED further agrees to hold harmless and indemnify Al Heaps & Associates Inc., its agents and the practice owner(s) in the event of disclosure of any information or documentation of said practice(s) received by the UNDERSIGNED, except as herein noted.

The UNDERSIGNED acknowledges that Al Heaps & Associates Inc., Al Heaps,  (Broker), and all other agents of Al Heaps & Associates Inc., are, or will be acting as agents of the Seller(s) of the practice(s) listed with Al Heaps & Associates Inc.

THE UNDERSIGNED AGREES TO RETURN TO AL HEAPS & ASSOCIATES INC., IN A TIMELY MANNER, AND/OR UPON THE VERBAL OR WRITTEN REQUEST OF AL HEAPS & ASSOCIATES INC., OR ANY OF ITS AGENTS OR THE PRACTICE OWNER, ALL INFORMATION PROVIDED PERTAINING TO ANY PARTICULAR PRACTICE SALE/PURCHASE THAT THE UNDERSIGNED HAS RECEIVED FROM AL HEAPS & ASSOCIATES INS., ITS AGENTS AND/OR THE PRACTICE OWNER.

FACSIMILE TRANSMISSIONS:  The UNDERSIGNED agrees that Facsimile transmitted documents and the signatures thereon shall be considered as binding.

Signature                                                                          Date

Name  (please print)

Mailing Address:

Email Address: Phone:         

Graduation University and Year: