Client Intake Form

Full Name*

First NameLast Name

Contact Number*

Please enter a valid phone number.

Email Address

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you identify as a member of one of the following groups? (optional--check all that apply)

Youth under 39 years of ageWomenFrancophonesIndigenous people (First Nation, Inuit or Metis)Racialized/persons of colourBlack communitiesNewcomers to Canada (landed immigrants who came to Canada up to 5 years prior to a given census year)People with disabilitiesTwo-Spirit, Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and sexual and gender diverse communities (2SLGBTQI+)

Business Name*

Those without a name can indicate 'TBD'

Main business activity*

What products/services are you planning to sell?

Position within company

Year established

Operating Status*

Legal form

Location type*

Service Area

Import/Export*

Number of full-time employees including owner(s)

Number of part-time employees including owner(s)

What date and time work best for you? We will do our best to accommodate. Please note: appointments are not confirmed until you receive an meeting invitation from a member of our team.

What services are you interested in?

How did you hear about The Business Enterprise Centre or Timmins Economic Development?

Would you like to be notified about our upcoming workshops and funding programs?*

YesNo

Timmins Economic Development and its service providers will not disclose personal information to the third parties other than in compliance with applicable federal and provincial privacy laws and, in particular the requirements for with the consent of our clients. Clients provide consent to the use and disclosure of personal information for statistical or scholarly study or research purposes, which information will be used or disclosed in such a manner that will insure its confidentiality. Timmins Economic Development does not view information that if freely available such as, but not limited to, business name(s) and contact information as personal information.

Signature*