Medicine ShoppeŽ Pharmacy Franchise Information

International Master Franchise Request Form:
Medicine Shoppe International, Inc. appreciates your interest in our operating system. We look forward to sharing with you the many benefits offered to our master franchisors. The information below will help us recommend the appropriate opportunity based on your experience. Please remember this information is confidential. * Indicates Required Fields
First Name	Required Item *
Last Name	Required Item *
Company Name
Street Address	Required Item *
City	Required Item *
State, Province or Region	Required Item *
Postal Code	Required Item *
Country	Required Item *
Required Item Registered Pharmacist Investor Other *
Daytime Phone	Required Item * include area code
Evening Phone	include area code
E-mail Address	A valid e-mail address is required * (required for request confirmation)
Your Company Web Site
In what country would you like to operate your Medicine Shoppe^Ž Pharmacy master franchise?	Required Item *
Personal Financial Information:
Approximate Net Worth (US Dollars)	Required Item * Net Worth: The value of all of a person's assets, including cash, minus all liabilities. Examples of assets are: cash, securities, accounts receivable, inventory, office equipment, a house, a car, and other property.
Liquid Funds Available	Required Item * Liquid Funds: Assets held in cash or in something that can be readily turned into cash.
How did you learn about The Medicine Shoppe^Ž Pharmacy?	Required Item Saw or visited a Medicine ShoppeŽ Pharmacy Friend or collegue Magazine ad Trade show Web site Other *
* Required Fields