INTAKE FOR REFERABLE BUSINESSES Use This form to complete intake for business referrals from the Chamber and put together a profile for your business for best referral match possible. SPECIALS TO OUR REFERRALS Section to gather information about specials you would like to offer to our referrals as an incentive to buy your product and/or services. Would you offer a special deal for the referrals from the chamber? * Select option... Yes No Maybe What type of discount would you offer? * % Off, specific $ amount, buy 1 get 1 free, etc.. Who will be the person in your business that will be handling our referrals? * Select option... Me My Staff Both Who will be providing Service to our referrals? * Select option... Me My Staff Both Is you business able to provide service in Spanish? Yes No PRODUCTS AND SERVICES Tell us up to 5 products or services your company currently offer PRODUCT AND/OR SERVICE 1 * PRODUCT AND/OR SERVICE 2 (optional) PRODUCT AND/OR SERVICE 3 (optional) PRODUCT AND/OR SERVICE 4 (optional) PRODUCT AND/OR SERVICE 5 (optional) What is your specialty? * What would you say makes you better than your competition? * Who do you sell to? * Homeowners Renters Youth Consumers Self employed Small Businesses Government Corporations Non profits ADVERTISING & PROMOTION Section to gather information about how your business currently do to acquire new customers What do you currently use to promote your business * Word of mouth/Referrals/Recommendations Paid advertising offline (Newspapers/Magazines/Bulletins) Paid advertising online (Google/Facebook/Instagram/Yelp/Other) Special events/Trade shows/Business Expo/Event sponsorships Other In Average, What is your current budget to promote your business per month? If currently none, what has been your avg budget in the past? COMPANY INFORMATION: If no business (example: consultant, coach, or sole-proprietorship, student, etc), provide owner or representative information. DO YOU HAVE A RETAIL/PUBLIC OFFICE LOCATION * Select option... Yes No COMPANY NAME * Business Address Information Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC 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 DC Zip/Postal Code * TEL: * EMAIL: * WEBSITE: * No. OF EMPLOYEES (1 if self-employed) * HISPANIC OWNED * Select option... Yes No DATE BUSINESS STARTED Format: M/d/yyyy CERTIFICATIONS List any licenses, certificates, special permits that you or your business may bave LANGUAGES SPOKEN BY EMPLOYEES * Select option... English Spanish Both COMPANY REPRESENTATIVE INFORMATION: Name Block - Simple First Name * Last Name * TITLE * COUNTRY OF BIRTH LANGUAGE PREFERENCE * Select option... English Spanish Both CEL: * EMAIL * Representative Address Information You may use business information if same one as business location Address Line 1 * Address Line 2 City * State * Select option... Alabama Alaska Arizona Arkansas California Colorado Connecticut DC 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 DC Zip/Postal Code * Language Preference For Communications * Select option... Yes No Both Volunteer Opportunities WHICH COMMITTEES WOULD YOU LIKE TO VOLUNTEER ON? Ambassadors Membership Special Events Business Advocacy Scholarships Business Education Communications Legislative affairs Business Resources Needs WHAT TIME COULD YOU ATTEND BUSINESS WORKSHOPS? Morning Noon Evenings Weekends AREAS YOU NEED MORE TRAINING OR CONSULTING TO IMPROVE YOUR BUSINESS: Accounting Promotion/Marketing HR Issues Social Media Taxes Permits/Special licenses Other IS THERE ANY OTHER SERVICES YOU WOULD LIKE US TO PROVIDE?