BOOK-SMART Registration Form

1
Name* This field is required.
First Name
Last Name
2
How did you hear about us?* This field is required.
Please Select
Please Select
Social Media
Word of Mouth
Referred by Current Client
3
Who referred you? * This field is required.
First Name
Last Name
4
How many workable leads do you have for our team to call?* This field is required.Unresolved leads or bad phone numbers are not considered workable
Please Select
Please Select
Less than 100 (Ineligible for Service)
100-150
150-200
200+
Bronze/Silver requires 100 to 200. Gold requires 200+
5
Service Level* This field is required.
Please Select
Please Select
BRONZE - 4 to 5 presentations
SILVER - 8 to 10 presentations
GOLD - 16 to 20 presentations
6
Lead Type* This field is required.
Please Select
Response Cards + Referrals
Policy Owners
7
Referral Boost?* This field is required.By selecting YES, Book-Smart will also call your referral leads for you. All you need to do is include your Callers name and Phone Number in the 3 way group text
Please Select
Please Select
Yes
No
8
Best Phone Number for clients to reach you* This field is required.
Area Code
Phone Number
9
Email* This field is required.
example@example.com
10
Field Days* This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
11
Any schedule exceptions* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
Ex. Personal Appointments etc.
12
Start Date & Time* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
Date
Month
Day
Year
9
1
2
3
4
5
6
7
8
9
10
11
12
Hour
20
00
10
20
30
40
50
Minutes
AM
AM
PM
13
First Appt Time* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
14
Last Appt Time* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
15
Comments
16
What US states will you need us to call for?* This field is required.If using a desktop, please hold CTRL / Command when selecting multiple territories
Please Select
ALL
NONE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
17
What CAN provinces will you need us to call for?* This field is required.If using a desktop, please hold CTRL / Command when selecting multiple territories
Please Select
ALL
NONE
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
18
What is your local timezone?* This field is required.
19
Calendly is required, Please provide your Link* This field is required.
20
Zoom credentials to share with your clients* This field is required.
21
Additional Back Up Presentation Platforms* This field is required.
Please Select
Google Duo / Meets
Facetime
Whatsapp
22
ID Badge* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
How would you prefer we handle call backs for missed appointments/no shows?* This field is required.
Please Select
Please Select
Book-Smart calls within 24 hours to re-schedule
Agent calls themselves
Should be Empty: