Client in-take form: Let's get to know you

Entrepreneur

First Name

Last Name

Phone Number

Email

Street Address

City

Postal Code

State/Province

Constituent Info - Individuals

Business Name

Years in Business

Business Registered with State

Yes

No

Business Plan

Yes

No

What is your business revenue?

0 - 50K

50k - 100k

100k - 250k

Over 250k

What is your preferred form of communication?

Online/ Virtual

Offline/ In-person

Both

What services are you looking for from ACER?

Website Design/Development

Business Planning

Accounting

Financial Planning

Brand Development

Marketing/PR

Human resources

Legal & Insurance

Access to funding

How many hours a week are you looking to work on your business within the program?

What business challenges do you wish to achieve in your session with the consultant?

Is there anything else you want to share about your business?

Outcome Reporting

Are you an ex-offender?

Yes

No

Prefer not to disclose

Who referred you to this program?