Floor Coverings International - Prospective Client Intake Form

Thank you for taking a few minutes to provide some valuable information to help us get to know you a bit. At the end of this brief survey, you will be invited to schedule a 30 minute introductory call to learn more.

1. Please provide the following contact information: *This question is required.

First Name

Last Name

Email Address

Phone Number

Legal Company Name

Street Address

City

State

Zip

Country

2. Please provide the contact information for any other individuals we might need to contact in the future (if applicable):

Space Cell	First Name	Last Name	E-mail	Phone
1	1: First Name	1: Last Name	1: E-mail	1: Phone
2	2 : First Name	2 : Last Name	2 : E-mail	2 : Phone
3	3: First Name	3: Last Name	3: E-mail	3: Phone
4	4: First Name	4: Last Name	4: E-mail	4: Phone

3. Entity type: *This question is required.

4. Employer Identification Number (EIN): *This question is required.

5. Date of organization (MM/DD/YYYY): *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

6. How many employees/contractors do you have, or anticipate having within the next 3 months (approx.)? *This question is required.

Employees
Contractors