Intake Form

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:*

Business / Office Hours:

: HH

MM

Payment Methods Accept [Highlight all that apply]:*

In Business Since:*

Primary Keyword / Tags:*

Business Description - Short (200 Characters Max):*

Business Description - Long:

Business Logo: Upload Here

Photos (Min 10 Photos): Upload Here

Section Break

Photo 1

Photo 2

Photo 3

Photo 4

Photo 5

Photo 6

Photo 7

Photo 8

Photo 9

Photo 10

Video URL (Try to give 5 Videos): (IF) url

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)*

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)

Wordpress Login info: username/password*

Google Business login and url:*

Domain email account for US: please setup an email acct @your domain.com for us to use.

Note: Previous Business Name, Address & Phone for editing business: (If business was submitted many times by you or other SEO worker)

Email

This field is for validation purposes and should be left unchanged.