ROUTING:
Director [Partner 3]
[Partner 1] [Partner 4]
[Partner 2]
C L I E N T Completed By: Status: Active Client Date: Active Prospect
(Check one)
I N F O R M A T I O N Client Number: Engagement Number:
Active Referral Source
Engagement Description:
Retain Files Indefinitely? Yes No
NAME and ADDRESS Client Name: Address Line One: Address Line Two: Address Line Three: City: Telephone #: Client Type*: Federal ID#: Primary Director: State: Fax #: Fiscal Year End: Social Security #: Bill Manager: Tax Reviewer: Zip:
MAILING ADDRESS (if different) Attention Name: Client Name: Address Line One: Address Line Two: Address Line Three: City: Email Address: Department*: State: Zip:
C
F
(Check one)
N
SIC Code**:
Spouse Social Security #: Client’s Annual Revenue*: Client’s # of Employees*:
C O N T A C T Contact Name Telephone
(Enter code before #)
I N F O R M A T I O N Email Title Salutation 1 2 1 2 1 2 Mailings
(Please circle – see below)
Telephone2
(Enter code before #)
3 4 3 4 3 4
5 6 5 6 5 6
Codes for Phone #’s:
C = Cell H = Home W = Work P = Pager F = Fax
Mailings:
1 = Newsletter – Quarterly Think Black Ink 2 = Newsletter – Quarterly Technology 3 = Planning Guide 4 = Payroll Deposit Schedule 5 = Special Year-End Mailing (calendar, card, etc.) 6 = Newsletter – Family Business Today
B U S I N E S S Employee Responsible for Acquiring Client: Referred How*? Law Office: Bank: Comments:
D E V E L O P M E N T
I N F O R M A T I O N
Referral Responsible for Acquiring Client:
Attorney Name: Banker Name:
Phone #: Phone #:
*Please refer to the back of this form for these codes. **SIC Code: Please refer to Consolidated SIC Code Listing which is located in Outlook Public Folders under Forms.
SERVICE INFORMATION
Service Tax Preparation Tax Planning Audit Review Exam Compilation Controllership Payroll Preparation Payroll Quarterly Payroll Tax Y Fee Service Human Resource Consulting Predictive Index Information Technology Consulting/Advice WYFA Services: Insurance Retirement Plan Design Investments Other: Other: Y Fee
Engagement Fee:
CODES
Client Type: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 C F N 1 2 3 4 5 6 7 8 9 = = = = = = = = = = = = = = = Attorney Bank C Corporation Credit Union Individual Joint Venture NPO-GFP Training Seminar NPO–Grant Funded Organization NPO-Private Foundation NPO-Trade/Membership Association Partnership Pension/Profit Sharing Sole Proprietorship Trust Sub S Corporate Client’s # of Employees: 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 10 Engagement Fee: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 – 10 11 – 20 21 – 50 51 – 100 101 – 150 151 – 200 201 – 250 > 250 Client Expansion Personal Contact Client “Introduction” Direct Mail Public Relations or Advertising Programs Banker/Attorney “Introduction” (or “other” referral
source)
Referred How?
Department:
= Commercial = FIG = NPO = = = = = = = = = $0 - $249,999 $250,000 - $499,999 $500,000 - $999,999 $1M - $4M $5M - $7M $8M - $14M $15M - $24M $25M - $49M $50M
NPO RFP GFP Training, Direct Mail, etc. GFP Internet Service Merger/Acquisition (i.e., McNally) $0 - $500 $501 - $1,000 $1001 - $1,500 $1,501 - $2,500 $2,501 – $3,500 $3,501 – $5,000 $5,001 - $7,500 $7,501 - $10,000 $10,001 - $12,500 $12,501 - $15,000 $15,001 - $20,000 $20,001 - $30,000 $30,001 - $40,000 $40,001 - $60,000 $60,001 +
Client’s Annual Revenue:
Consolidated
100 1000 1500 2000 4000 4800 4900 5000 5200 6000 6100 6200 6300 6500 6700 7300 7900 8000 8100 8200 8300 8400 8500 8600 9100 99999
SIC
Listing
Agriculture Mining Construction Manufacturing Transportation Communications – Radio/TV Public Utilities Wholesale Trade Retail Trade Banks – Depository & Non-Depository Credit Unions Security & Commodity Brokers Insurance – Carriers, Agents, Brokers, Service Real Estate Holding Companies, Trusts, Investing Services – Business Services – Other Services – Medical/Dental Services – Legal NPO – Education/Schools NPO – CAP Agencies/HS NPO – SDA NPO – Community-Based Organizations NPO – Membership Organizations/Trade Associations Public Administration/General Government Individuals