EPIC Client Intake Form

Name

First NameLast Name

Name of Organization

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Type of Entity (Non-profit, Corporation, Small Business, etc)

Year Established

Mission Statement/Objectives:

Client Operating Area (geographical - nationally, state, county, local areas)

Are you currently represented by another lobbyist or advocacy group?

YesNo

If yes, please specify who:

What are your primary reasons for seeking new representation?

Describe the issues you are facing that require advocacy or legislative support.

What are your short-term goals (1-2 years)?

What are your long-term goals (3-5 years)?

Are there specific legislative or regulatory bodies that are critical to your interests?

Who are your key stakeholders and what are their interests?

What current relationships do you have with governmental or regulatory bodies?

Preferred method of communication (E-mail, Phone, In-Person, etc):

Frequency of updates (Weekly, Monthly, As-needed, etc.):

List any entities or individuals that could pose a conflict of interest with your representation by EPIC Policy Group:

Do you require additional services such as public relations, crisis management, or strategic planning?

Are there any specific deliverables or outcomes you expect from these services?

What is your budget for lobbying/advocacy services?

Do you have allocated funds for incidental expenses (travel, legal fees, etc.)?

Please attach any relevant documentation such as previous position papers, testimonies, or reports.