Client Intake Form

Please enter as much information below as you can. We will use this information to create or improve your online listings.

Business Information
Company Name:*
Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Address 2: (IF)
Street Address City State / Province / Region ZIP / Postal Code Country
Phone:*
Fax: (IF)
Toll Free Number: (IF)
Website:*
Profile Email / Web Mail / Business Email: (IF)
Business Type / Category:*
Products / Services:*
Products / Services:*
Business / Office Hours:

: HH:MM

HH:MM
Days Open
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Notes
Please explain if you have different open/close times on different days. For example, if you are open 8:00-5:00 M-F, but only open 10:00-3:00 on Saturday.
Payment Methods Accept [Highlight all that apply]:*
- Cash
- Cheque
- Debit Card
- Visa
- Master Card
- American Express
- Discover
- Diners Club
- PayPal
- Invoice
- Financing
- Travelers Cheques
- Euro Card
In Business Since:*
Primary Keyword / Tags:*
Business Description - Short (200 Characters Max):*
Business Description - Long:
Business Logo: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 1: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Please use the individual photo uploads to send us 10 photos of your team, office interior, office exterior, signage, products, etc.
Photo 2: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 3: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 4: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 5: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 6: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 7: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 8: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 9: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Photo 10: Upload Here
Accepted file types: jpg, jpeg, png, gif.
Video Links:

Try to give 5 Video URLs (links) to any videos you may have created for your business.
Additional Information
Tag Line / Business Slogan: (IF)
Specialties (exclusive products, areas of expertise): (IF)
Cities Served / Counties Served / Areas Served: (IF)
Language Spoken: (IF)
Wi-Fi: (IF)
Parking Available (Yes/No): (IF)
- Yes
- No
Reviews: (IF)
Testimonials: (IF)
Coupons & Specials [Get more business by adding an offer or discount. You can update or delete your coupon at any time]: (IF)
Offers [like this - 20% off all haircuts, Expires: Oct 15, 2013]: (IF)
Brand Names Carried: (IF)
Affiliations (BBB Member, Sites / Trade License#, chamber of commerce etc...): (IF)
Social Media Page URLs (Face Book, Twitter, Blog): (IF)
Owner Information
Name*
Position / Job Title:*
Owner / Contact Person Gender:*
- Male
- Female
Owner / Contact Person Date of Birth: (IF)*
MM slash DD slash YYYY
Owner / Contact Person Bio: (IF)
Owner / Contact Person Location: (IF)
Street Address City State / Province / Region ZIP / Postal Code Country
Owner / Contact Person Photo: (IF)
Accepted file types: jpg, jpeg, png, gif.
Website Login info: username/password
Google Business login and url:
Domain email account for us:
Please set up an email account like web@yourdomain.com for us to use. Please provide login info here.

Client Intake Form

Business Information

Additional Information

Owner Information

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