Candidate Profile Form

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Non-Disclosure Agreement

Whereas, In order to evaluate various potential associate opportunities and/or practice purchase opportunities (hereinafter "Opportunities") the undersigned may be informed of, provided, presented and/or entrusted with various personal, business and other confidential information and documents by Henry Schein Nationwide Dental Opportunities (hereinafter referred to as "HS NDO"), a division of Henry Schein Financial Services, LLC (HSFS), its agents, and/or representatives; and

Whereas, Disclosure of said confidential information, documents, and/or the names of the parties involved may result in serious economic and other consequences to the parties involved, including their agents, representatives and HS NDO;

Now, therefore, the undersigned party hereby agrees as follows:

1. Except as provided in section 4. hereinafter, not to disclose or discuss any information, documents, the names of the parties or circumstances associated with any information disclosed to the undersigned by HS NDO or the party whose information is being disclosed, unless said disclosure has been authorized in writing by HS NDO.
2. Except as provided in section 4. hereinafter, not to disclose to anyone any ideas or concepts, information, documents, contracts, or procedures given to or discussed with the undersigned by HS NDO for the purpose of considering or entering into any agreement involving an Opportunity for which HS NDO is providing consulting services.
3. Not to make any copies, reproductions or any other records of any information or documents presented to the undersigned for the purpose of evaluating a potential opportunity including any materials, contracts or other documents entrusted to the undersigned by HS NDO for the purpose of evaluating the Opportunity.
4. Notwithstanding anything to the contrary contained herein or as previously prohibited, the undersigned shall be allowed to disclose to the undersigned’s legal, accounting, or other personal advisor and/or spouse any information disclosed to the undersigned without obtaining the previously mentioned prior written consent, providing that the undersigned acknowledges and agrees to accept personal responsibility for any damages incurred as the result of any subsequent disclosure of that information by the party to whom the undersigned has disclosed said information.
5. To hold HS NDO, HSFS, and its agents and representatives harmless from any action taken as a result of the undersigned’s disclosure of said information, or the subsequent disclosure by any agent of the undersigned to who said information was disclosed.
6. To return immediately upon request by HS NDO all materials, data, contracts, documents, or other materials entrusted to the undersigned for the purpose of evaluating the Opportunity.
7. Not to directly or indirectly contact the owner or prospective employer whose position/opportunity is being considered, or any current or past employees or representatives of said owner or employer, without prior written authorization from HS NDO.
8. The undersigned agrees and acknowledges that the agreements made herein shall continue after the closing of any legal transactions between the undersigned and the party whose information has been disclosed.

I understand that any false, misleading or omitted information in this data form may constitute sufficient cause for rejection of my application, or if employed, grounds for dismissal.

You may be required to submit to a background check and drug screen after receiving a conditional offer of employment. If you disagree, you will not be considered for employment. I further understand that employment by a dental practice may be contingent upon the results of reference checks that a dental practice may conduct for employment purposes as part of the application process. I authorize HSNDO to investigate all statements made by me during the placement process. I also hereby authorize all persons, schools, companies, corporations and organizations named in this data form (and accompanying documents, if any) and law enforcement agencies to release any information concerning my background, and I hereby release HSNDO and them from any and all claims of liability that may arise out of releasing such information.

Henry Schein Nationwide Dental Opportunities will be held harmless for any misinformation provided by the Candidate or Client.

In order to successfully submit this form, you must electronically sign this document. By signing this document, you accept the Non-Disclosure Agreement above. Additionally, by completing this interview and submitting this data form, you attest that all information provided is true and correct.

Please add your electronic signature to this document by typing your name in the signature box below.