Cleonmaye Client Form

Date

Todays Date

First Name

Last Name

Gender

FemaleMalePrefer Not to Say

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone Number

Email Address *

Alternate E-Mail Address *

Name of Company

Company Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Company Formation

Employer Identification Number (EIN)No dashes or special characters

In what state was the company formed

Other

Is the company for-profit or not-for-profit *

For ProfitNot For Profit

What type of goods or services does your company sell?0 / 150

Who are your customers?

How many locations does you company have?

12-34-56+

Gross revenue/sales for the previous year?

Profit +/Loss - for the previous year?

Is your company 8(a) or M/WBE certified?YesNo

Have you done government contracting?YesNo

Are you or any majority owner in the company disabled?YesNo

Describe the business problem that you are having?

Would you like to receive a 15% discount on our management consulting packages by opting into one of our subscription services?YesNo

Which service would you like to subscribe to for your 15% discount?

Bi-Weekly 1/2 hour consultation- $199/mo.Business Coaching-$299/mo.Launch Assistance- $399/mo.Greet-a-Gram-$49/mo.

Preferred Appointment Date

Preferred Appointment Time

Hours

Minutes

Confidentiality Agreement *AgreeDisagreeI request management consulting service from the Cleonmaye Corp. or a Cleonmaye Corp. Network Partner. I agree to cooperate should I be selected to participate in surveys designed to evaluate Cleonmaye Corp. services. I permit Cleonmaye Corp. or its agent the use of my name and address for surveys and information mailings regarding Cleonmaye Corp. products and services. I understand that any information disclosed will be held in strict confidence. (Cleonmaye Corp. will not provide your personal information to commercial entities.) I authorize Cleonmaye Corp. to furnish relevant information to the assigned management consultant(s). I further understand that the consultant(s) agrees to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this consulting relationship. In consideration of the consultant(s) furnishing management or technical assistance, I waive all claims against Cleonmaye Corp. personnel, and that of its Network Partners and organizations, arising from this assistance. Use of Information: The information in this form is to be provided by individuals and businesses seeking management consulting from Cleonmaye Corp. or a Cleonmaye Corp. Network Partners. The information is collected to help Cleonmaye's continuing improvement of business management consulting products and services.

Signature

Date