MEDOFFICE™ SYSTEMS, INC.

Thank you for your interest in becoming a franchisee with MedOffice™ Systems, Inc. Once you
have reviewed our on-line franchise information fill out and complete our information request form. There
is no obligation to buy when you fill out this form, but it does tell us that you have an above average
interest in our franchise.

Franchising has many benefits and we believe the time has never been better to join the MedOffice™ network of growing Billing Centers. Within a few days after submitting this information request, you will receive an information package that will explain to you why we are the #1 leader in our industry. We look forward to the opportunity of having you join the MedOffice™ family. Someone from our Headquarters will be contacting you soon to answer any questions you may have. In the interim, please feel free to call 1-800-400-9558 with any other questions.

For your protection all personal information submitted will be kept in
the strictest confidence and will never be sold to mailing lists or anyone.


Prospective Licensees will not be discriminated against because of race, creed, color, sex, age, national origin or handicap.


First and Last Name:   Street Address:

Home Phone:   Business/Message phone:   City:   State:

Zip Code:   Email Address:   Area Applying For:

How soon are you available?   How did you learn of our organization?

Current net worth:   Amount of cash available for investment:




High School:   College:   Course of Study:

Years completed:   Did you graduate?   Special training, skills.

Degree in...   Other School:



  
If you prefer you can fill out this form, print it on your printer and then mail it to us via the US Postal Service.

Mail to:
MedOffice™ Systems Corporation
7676 Hazard Center Drive, Fifth Floor
San Diego, California 92108

or Fax to: 1-800-503-9461


Order Form