New 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

Enter your EXACT address as it is listed with the Post Office/on your mail. For example, "Suite 1550" will be "Ste 1550" in the Post Office format. Put Suite or Unit #'s all on same line in street address field.
Address 2: (If more than one location)
Street Address City State / Province / Region ZIP / Postal Code Country
Phone:*
Fax: (If applicable)
Toll Free Number: (If applicable)
Website:*
Profile Email / Web Mail / Business Email:*

This is your primary email used for your business.
Business Type / Category:*

This is your main business/keyword. Ex: chiropractor, lawyer, contractor.

Main Products/Services You Offer:*

Enter the top 3 to 8 services or products that you wish to rank for and sell more of. For example, if you are a chiropractor, you would put chiropractic services, massage services, physical therapy services, car accident treatment, etc...(Add another row by hitting the plus sign).

Opening Business / Office Hours:

: Hours

Minutes

AM/PM
Closing Business / Office Hours:

: Hours

Minutes

AM/PM
Days Open (check all that apply)
- Mon
- Tue
- Wed
- Thurs
- Fri
- Sat
- Sun
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:*

Enter the main keywords you wish to rank for/agreed upon
Business Description - Short (200 Characters Max):*
Please write a general short description of your business and include as many of your main category keywords as possible while still making sense and being readable.
Business Description - Long:
Please write a general description of your business and include as many of your main category keywords as possible while still making sense and being readable.
Business Logo: Upload Here
Accepted file types: jpg, jpeg, png, gif.
HIghest resolution possible; .JPEG, .PNG formats preferred - do NOT use a .PDF format.
Photos (Min 10 Photos): Upload Here
Accepted file types: jpg, jpeg, png, gif.
If you have any high quality, high resolution photos, please upload in .JPEG or .PNG format. If you do NOT have any photos, we will purchase/provide them.

Video URL (Try to give 5 Videos):

If you have any videos already created, please share the URL's here. If not, we will be creating some together.

Additional Information
Tag Line / Business Slogan: (Leave blank if none)
Specialties (exclusive products, areas of expertise): (Leave blank if none)
Cities Served / Counties Served / Areas Served:
Languages Spoken:
Wi-Fi: (Leave blank if none)
Parking Available (Yes/No): (IF)
- Yes
- No
Reviews: (Leave blank if none)
Testimonials: (Leave blank if none)
Coupons & Specials [Get more business by adding an offer or discount. You can update or delete your coupon at any time]: (Leave blank if none)
Offers [like this - 20% off all haircuts, Expires: Oct 15, 2013]: (Leave blank if none)
Brand Names Carried: (Leave blank if none)
Affiliations (BBB Member, Sites / Trade License#, Chamber of Commerce etc...): (Leave blank if none)

Existing Social Media Properties

URL 1	URL 2	URL 3	URL 4

Please list any social media properties that you currently know of, including Facebook, Twitter, LinkedIn, Yelp, Pinterest, Instagram, Snapchat, Foursquare, Manta, etc...You may add up to 20 properties.

Owner Information
Name*
Position / Job Title:*
Mobile Phone*
Owner / Contact Person Gender:*
- Male
- Female
Owner / Contact Person Date of Birth:*
MM slash DD slash YYYY
Owner / Contact Person Bio:
Owner / Contact Person Location:
Street Address City State / Province / Region ZIP / Postal Code Country
Owner / Contact Person Photo: (IF)
Accepted file types: jpg, jpeg, png, gif.
Wordpress Login info: username/password (If no website, type NONE)*
If you have an existing Wordpress site, please provide your admin username and password.
Google Business login and url: (If no Google My Business/Map Listing, type NONE)*
If you have an existing Google My Business (GMB) or Google Maps listing, please provide the gmail account and password so we may gain access.
Domain email account/URL/user/password for Us:

We will need to create a domain email for our marketing use; please create an email called [email protected] and include the user and password for us to access. This will be used to create/manage all your online properties under one email, of which you will own and we will both have access. If you don't know how to do this, leave blank.
Note: Previous Business Name, Address & Phone for editing business: (If business was submitted many times by you or other SEO worker)