Franchise Application Form

Thank you for your interest in a Nuviva franchise

 Franchisee Qualifications

Applicants must meet the following basic requirements to be considered for a Nuviva franchise:

#1 A commitment to helping people succeed!

If you are NOT committed to the #1 requirement then we thank you for your interest and suggest you seek an alternative franchise.

  • Liquid assets above $250,000
  • Physician or physician group with an existing patient base
  • Investors are welcome if they have a physician or physician group with a patient base to partner with
  • A commitment to protecting and enhancing the Nuviva brand and ethos

Please complete the form below and a member of our Business Development team will contact you.    This form will aid you in preparing personal information for the confidential use of our Executive Committee.  The completion of this form places no continuing obligation on either Nuviva or the applicant.

PERSONAL DATA

 
*Name:
 
Address:
 
City:
 
State:
 
Zip:
 
Home Phone:
 
Business Phone:
 
Cell Phone:
 
*Email:
 
Best time to call?
 
Part of the Nuviva franchise program requires franchisees to have a fully qualified medical physician as part of the team.  
Are you a physician?
Yes
No
If you are not a physician Nuviva can help you in identifying and recruiting a suitable candidate to join your team.  
If Yes, What type of physician?
 
Are you part of a group practice?
Yes
No
 
How many physicians in the practice?
 
How many patients does the practice have?
 
How did you learn about Nuviva?
Referral from Doctor or Medical Professional
Nuviva client
Internet
Current Nuviva Franchise Owner
Other
 
Have you ever worked at Nuviva?
Yes
No
 
If Yes which clinic?:
 
Have you ever failed in business or compromised with creditors?
Yes
No
 
If yes, please give details including when, where, circumstances:
include any remaining liabilities 
Are any lawsuits pending against you?:
Yes
No
 
If yes, give details:
 
What is your approximate net worth?
$500,000 - $649,000
$650,000 - $999,000
$1,000,000 +
 
How much in liquid assets do you have available for investing – excluding 401K or IRAs?
$250,000 - $399,999
$400,000 - $549,000
$550,000 - $699,999
$700,000 +
 
Will you have investors/partners?
Yes
No
 
How much in liquid assets do your partners have available for investing – excluding 401K or IRAs?
$250,000 - $399,999
$400,000 - $549,000
$550,000 - $699,999
$700,000 +
 

BUSINESS PLAN

 
What type of Nuviva franchise business are you interested in?
Single clinic
Multiple clinics
Regional territory
 
Which geographic area(s) are you interested in?
 
If that area is not available, are there other areas of interest? Please list:
 
When would you like to open your Nuviva franchise business?
3-6 months
6-12 months
1 year or more
 
Is relocation an option for you?
Yes
No
 
Why do you want to become a Nuviva Franchisee?
 
Would you expect to devote your full time to this Business?
Yes
No
 
If NO, what percentage?
 

FRANCHISE DOCUMENTS

 
All Nuviva franchise documents including our Franchise Disclosure Document (FDD) are available in multiple formats.  
When it is time to receive these documents FDD (Franchise Disclosure Document), what format would you prefer?
Hard Copy (paper copy)
PDF via E-mail; you must have an e-mail account capable of receiving large attachments, e-mail software, and Adobe Acrobat software to view the FDD.
 
By submitting this information you warrant that this information is true and correct and that Nuviva may consider this information as true and correct until a written notice of change is given to Nuviva by you.