First Name: Last Name: Country: USA Canada State/Province: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ---Canada-- AB BC MB NB NL NS ON PE QC SK City: Zip Code: Email Address: Telephone Number:     Structure of Practice: LLC PLLC Sole-Proprietorship Partnership Corporation Number of ODs: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+ Number of MDs: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+ Number of Employees: 1 2 3 4 5 6 7 8 9 10 11-15 16-20 21-25 26-30 31+     Years in Practice: Years at Location: Dispensary: Yes No     Yearly Revenue: Yearly Net Income: Appraisal Value: Asking Price:     Reason for Sale: Comments: