Join the Network of Doctors: Apply

The unique strength of becoming associated with TSO is the independence you have over your own practice and total control over the decisions that affect your office. The decisions are yours because our organization is owned by doctors and driven by doctors who understand doctors. We believe this is critical to strengthening the professional and financial success of each TSO office.

Name:

Business address:

City:

State:

Zip:

Business telephone:

Format: 123-456-7890

E-mail:

Professional Information

What is your current situation?:

Employee

Private Practice

Are you affiliated with any company or chain organization?:

Yes

If "Yes", which company or organization?:

How long have you been in your current position?:

If less than 2 years, what was your previous position:

Education Information

Optometry school:

Year graduated:

Undergraduate school:

Optometry license number:

Professional organizations:

General Information

Have you ever had any previous affiliation with TSO?:

Yes

If "Yes", explain:

Have you ever declared bankruptcy?:

Yes

If “YES”, explain the circumstances:

Have you ever been subject to an action which resulted in action taken by the Board of Optometry?:

Yes

If “YES”, explain:

Location preference for a TSO member office:

Professional References

Reference 1

Name:

Address:

Phone:

Reference 2

Name:

Address:

Phone:

Reference 3

Name:

Address:

Phone:

Financial Information

Bank

Name of Bank:

Account Number:

Bank

Name of Bank:

Account Number:

Other Parties Involved in the Ownership of the TSO Office

Others

Name:

Address:

Phone:

Others

Name:

Address:

Phone:

How do you plan to finance your TSO OFFICE?:

Personal Financial Statement

The following list of assets and liabilities is current as of the:

Assets

Cash on hand: $

Stocks / Bonds: $

Real Estate: $

Automobiles: $

Other Assets:

List other assets and ($) value

Total Assets: $

Liabilities

Notes payable to bank: $

- Secured: $

- Unsecured: $

Real Estate Mortgage: $

Other Liabilities:

List other liabilities and ($) value

Total Liabilities: $

Annual Income

2008: $

2007: $

2006: $

Credit Cards

Card 1

Company Name:

Account Number:

Balance: $

Card 2

Company Name:

Account Number:

Balance: $

Card 3

Company Name:

Account Number:

Balance: $

Card 4

Company Name:

Account Number:

Balance: $

Card 5

Company Name:

Account Number:

Balance: $

Notes payable to banks or financial institutions

Bank/Financial Institution

Company Name:

Account Number:

Balance: $

Bank/Financial Institution

Company Name:

Account Number:

Balance: $

Bank/Financial Institution

Company Name:

Account Number:

Balance: $

Bank/Financial Institution

Company Name:

Account Number:

Balance: $

Bank/Financial Institution

Company Name:

Account Number:

Balance: $