Client Intake Form
Clients who desire to pursue service with Urbanetectonics, LLC dba The BomaQ Companies must sign an initial client intake form. Potential clients may also opt to use our self-scheduler at our website to schedule a day and time to receive assistance in filling out this form or to schedule an appointment.
* Required
Email address
*
Your email
Name of the person(s) requesting service.
Your answer
Name of the business, organization, or entity.
Your answer
Contact Information:
*
Your answer
Select Industry:
*
Design, Engineering, or Construction
Facilities, Hospitality, Food Service, or Retail
Education, Multi-Media, or Technology
Oil Gas, Healthcare, or Manufacturing
Business Brokerage or Managerial
Other:
Select Entity Structure:
*
Sole Proprietor or Self-Employed
General Partnership
LLC, LLP, or PLLC
Professional Corporation, S-Corp, or C-Corp
Non-Profit, Public Agency, or Governmental Entity
Other:
Select Entity Stage:
Seed Stage
Early Stage
Mid Stage
Late Stage
Exit
Other:
Clear selection
Select Projected Enterprise Value:
< $25,000
$25,000 to $150,000
$150,000 to $350,000
$350,000 to $500,000
$500,000 to $750,000
$750,000 to 1.5 Million
1.5 Million to 3.5 Million
> 3.5 Million
Clear selection
Select Service & Need
*
Operations & Logistics
Human Capital Training
Facilities Care & Planning
Project Compliance Legalism
Marketing & Public Relations
Multi-Media & Technology
Safety, Security, & Emergency Preparedness
Data Warehousing
Asset & Inventory Management
Project Direction and Management
Other:
Required
What is the projected or planned budget allocated for this service or need?
< $25,000
$25,000 to $150,000
$150,000 to $350,000
$350,000 to $500,000
$500,000 to $750,000
$750,000 to 1.5 Million
1.5 Million to 3.5 Million
> 3.5 Million
Clear selection
Is there time or schedule constraints or parameters that would impact favorable service delivery and fulfillment?
Yes
No
Other:
Have you sent ALL relevant support documents to
information@urbanetek2.com
which would support accurate quote, proposal, or service matching activities?
Yes
No
Other:
Initial Consultation Delivery Preference:
*
On-Site Analysis and Assessment Walk Through
Marketing Meeting, Presentation, or Brown Bag Lunch n Learn
Video Conference Discussion on Service and Product Options
Email Questions about Contract Delivery, Signature, and Pricing Structure
Brochure, Marketing Materials, and a Follow-Up Phone Call
Other:
Required
Name three dates and times you would prefer to meet or indicate you will use our self-scheduler
https://t.co/92vOQmEdgb
which is also found at our website
www.urbanetek2.com
.
*
Your answer
I am the authorized signature of the Owner, Manager, or Administrator who has managing authority to make decisions on behalf of the said entity previously listed on this form:
*
Yes
No
Other:
Required
Authorized Signature. Please sign digitally here:
*
Your answer
Indicate the Current Time:
*
Time
:
AM
PM
Please indicate the date:
*
MM
/
DD
/
YYYY
Send me a copy of my responses.
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