15X Business Intake Form

1
Business Owner Name* This field is required.
First Name
Last Name
2
Business Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number* This field is required.
Area Code
Phone Number
4
Business E-mail* This field is required.
5
How did you hear about us?* This field is required.
Please Select
Please Select
Instagram
Clubhouse
Facebook
Youtube
Other (Please specify...)
6
Business Name:* This field is required.
7
Are you the primary decision maker?* This field is required.
Yes
No
8
What Industry are you in?
Entertainment
Auto
Beauty
Real Estate
Construction
Fashion
Food
Healthcare
Fitness
Government
Education
Finance
Agriculture
Retail
E-Commerce
Other
9
Please give a short description of what your business does:
Huge
Large
Normal
Small
Ok
Ok
10
Website Address
11
How long have you been in business?* This field is required.
12
Social Media Information:* This field is required.
Facebook:
Instagram
Twitter
YouTube
13
How many employees or contractors are currently employed by your business?* This field is required.
14
How many business partners do you have?* This field is required.
15
What are your main concerns with your business?* This field is required.
Business development (Foundation)
CRM Design (Database)
Business Credit Workshop
Social Media Management
Social Media Marketing
Website design or improvements
Copy Writing
HR & Legal Matters
Financing/Business Loans or credit lines
Business scalability
Team building
Project Management
Google Optimization
White Label Customer Service Support
Other:
Google Local Listing
Press Release (Get published & seen all over the internet)
16
What is your budget range?* This field is required.
$1000 to $1200
$1300 to $2500
$2600 to $4000
$5000+ and up
17
Are you open to being qualified for financing?* This field is required.We source personal and business loans/credit lines
Yes
No
18
Write a short description of your business needs and or concerns:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Would you like to get a copy of our FREE e-magazine every 3 months?
YESNO
20
Please understand that all personal information in this form is held confidential and will ONLY be used for business analysis and auditing purposes within our organization.
21
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