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FORM INSTRUCTIONS: Before entering any data, please gather all required information by clicking each section link below to familiarize yourself with the requirements. When ready to begin, complete the "Business Information" section, double check for accuracy, click "Submit", and proceed to the next form section. Continue this process until all form sections are completed. Note that it's normal for the form to load slowly due to complexity.

AJS.tabs.change(jQuery('a[href="#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-1"]'));
//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-1').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
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Business Information	IP: [entry.ClientIP]
Client Name	[entry.ClientName]
Date	[entry.DateFilled.formatDate(MMM dd, yyyy)]
Site Address	[entry.SiteAddress]
City / State	[entry.SiteCityState]
TaxID#	[entry.TaxID]
BusinessHoursOfOperation	[entry.BusinessHoursOfOperation]
LunchPeriodBegins	[entry.LunchPeriodBegins]
LunchPeriodTo	[entry.LunchPeriodTo]
PreferredPaymentMethod	[entry.PreferredPaymentMethod.label]

Date:

Client Name:

Site Address

City / State:

Tax ID#:

Business Hours of Operation:

Lunch Period From:

Lunch Period To:

Primary Business Contact1

Primary Business Contact2

Primary Business Contact3

Primary Business Contact4

Primary Business Contact5

Primary Business Contact6

Primary Business Contact7

Primary Business Contact8

Primary Business Contact9

Office Manager

Internal Technical Contact

Internal Billing Contact

AJS.tabs.change(jQuery('a[href="#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-2"]'));
//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-2').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});

	First / Last Name	Title / Position	Cell Phone #	Home Phone #	Office Phone # or Extension	Office / Personal Email
Administrative Contact Information	IP: [entry.ClientIP]
Owner/Executive #1	[entry.FirstLastNamePBC1]	[entry.TitlePBC1]	[entry.CellPhonePBC1]	[entry.HomePhonePBC1]	[entry.OfficePhoneOrExtensionPBC1]	[entry.OfficePersonalEmailPBC1]
Owner/Executive #2	[entry.FirstLastNamePBC2]	[entry.TitlePBC2]	[entry.CellPhonePBC2]	[entry.HomePhonePBC2]	[entry.OfficePhoneOrExtensionPBC2]	[entry.OfficePersonalEmailPBC2]
Owner/Executive #3	[entry.FirstLastNamePBC3]	[entry.TitlePBC3]	[entry.CellPhonePBC3]	[entry.HomePhonePBC3]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Owner/Executive #4	[entry.FirstLastNamePBC4]	[entry.TitlePBC4]	[entry.CellPhonePBC4]	[entry.HomePhonePBC4]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Owner/Executive #5	[entry.FirstLastNamePBC5]	[entry.TitlePBC5]	[entry.CellPhonePBC5]	[entry.HomePhonePBC5]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Owner/Executive #6	[entry.FirstLastNamePBC6]	[entry.TitlePBC6]	[entry.CellPhonePBC6]	[entry.HomePhonePBC6]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Owner/Executive #7	[entry.FirstLastNamePBC7]	[entry.TitlePBC7]	[entry.CellPhonePBC7]	[entry.HomePhonePBC7]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Owner/Executive #8	[entry.FirstLastNamePBC8]	[entry.TitlePBC8]	[entry.CellPhonePBC8]	[entry.HomePhonePBC8]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Owner/Executive #9	[entry.FirstLastNamePBC9]	[entry.TitlePBC9]	[entry.CellPhonePBC9]	[entry.HomePhonePBC9]	[entry.OfficePhoneOrExtensionPBC3]	[entry.OfficePersonalEmailPBC3]
Office Manager	[entry.FirstLastNameOM]	[entry.TitleOM]	[entry.CellPhoneOM]		[entry.OfficePhoneOrExtensionOM]	[entry.OfficePersonalEmailOM]
Internal Technical Contact	[entry.FirstLastNameITC]	[entry.TitleTC]	[entry.CellPhoneITC]		[entry.OfficePhoneOrExtensionTC]	[entry.OfficePersonalEmailITC]
Internal Billing Contact	[entry.FirstLastNameIBC]	[entry.TitleBC]	[entry.CellPhoneIBC]		[entry.OfficePhoneOrExtensionBC]	[entry.OfficePersonalEmailIBC]

Office Manager	Internal Technical Contact	Internal Billing Contact

Owner/Executive	Owner/Executive	Owner/Executive

Owner/Executive	Owner/Executive	Owner/Executive

Owner/Executive	Owner/Executive	Owner/Executive

Staff Member Contact

AJS.tabs.change(jQuery('a[href="#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-3"]'));
//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-3').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});

#	First / Last Name	Title / Position	Office Phone # or Extension	Office / Personal Email
Staff Member Contact Information		IP: [entry.ClientIP]
1	[entry.FirstLastNameSMC1]	[entry.TitlePositionSMC1]	[entry.OfficePhoneOrExtensionSMC1]	[entry.OfficePersonalEmailSMC1]
2	[entry.FirstLastNameSMC2]	[entry.TitlePositionSMC2]	[entry.OfficePhoneOrExtensionSMC2]	[entry.OfficePersonalEmailSMC2]
3	[entry.FirstLastNameSMC3]	[entry.TitlePositionSMC3]	[entry.OfficePhoneOrExtensionSMC3]	[entry.OfficePersonalEmailSMC3]
4	[entry.FirstLastNameSMC4]	[entry.TitlePositionSMC4]	[entry.OfficePhoneOrExtensionSMC4]	[entry.OfficePersonalEmailSMC4]
5	[entry.FirstLastNameSMC5]	[entry.TitlePositionSMC5]	[entry.OfficePhoneOrExtensionSMC5]	[entry.OfficePersonalEmailSMC5]
6	[entry.FirstLastNameSMC6]	[entry.TitlePositionSMC6]	[entry.OfficePhoneOrExtensionSMC6]	[entry.OfficePersonalEmailSMC6]
7	[entry.FirstLastNameSMC7]	[entry.TitlePositionSMC7]	[entry.OfficePhoneOrExtensionSMC7]	[entry.OfficePersonalEmailSMC7]
8	[entry.FirstLastNameSMC8]	[entry.TitlePositionSMC8]	[entry.OfficePhoneOrExtensionSMC8]	[entry.OfficePersonalEmailSMC8]
9	[entry.FirstLastNameSMC9]	[entry.TitlePositionSMC9]	[entry.OfficePhoneOrExtensionSMC9]	[entry.OfficePersonalEmailSMC9]
10	[entry.FirstLastNameSMC10]	[entry.TitlePositionSMC10]	[entry.OfficePhoneOrExtensionSMC10]	[entry.OfficePersonalEmailSMC10]
11	[entry.FirstLastNameSMC11]	[entry.TitlePositionSMC11]	[entry.OfficePhoneOrExtensionSMC11]	[entry.OfficePersonalEmailSMC11]
12	[entry.FirstLastNameSMC12]	[entry.TitlePositionSMC12]	[entry.OfficePhoneOrExtensionSMC12]	[entry.OfficePersonalEmailSMC12]
13	[entry.FirstLastNameSMC13]	[entry.TitlePositionSMC13]	[entry.OfficePhoneOrExtensionSMC13]	[entry.OfficePersonalEmailSMC13]
14	[entry.FirstLastNameSMC14]	[entry.TitlePositionSMC14]	[entry.OfficePhoneOrExtensionSMC14]	[entry.OfficePersonalEmailSMC14]
15	[entry.FirstLastNameSMC15]	[entry.TitlePositionSMC15]	[entry.OfficePhoneOrExtensionSMC15]	[entry.OfficePersonalEmailSMC15]
16	[entry.FirstLastNameSMC16]	[entry.TitlePositionSMC16]	[entry.OfficePhoneOrExtensionSMC16]	[entry.OfficePersonalEmailSMC16]
17	[entry.FirstLastNameSMC17]	[entry.TitlePositionSMC17]	[entry.OfficePhoneOrExtensionSMC17]	[entry.OfficePersonalEmailSMC17]
18	[entry.FirstLastNameSMC18]	[entry.TitlePositionSMC18]	[entry.OfficePhoneOrExtensionSMC18]	[entry.OfficePersonalEmailSMC18]
19	[entry.FirstLastNameSMC19]	[entry.TitlePositionSMC19]	[entry.OfficePhoneOrExtensionSMC19]	[entry.OfficePersonalEmailSMC19]
20	[entry.FirstLastNameSMC20]	[entry.TitlePositionSMC20]	[entry.OfficePhoneOrExtensionSMC20]	[entry.OfficePersonalEmailSMC20]
21	[entry.FirstLastNameSMC21]	[entry.TitlePositionSMC21]	[entry.OfficePhoneOrExtensionSMC21]	[entry.OfficePersonalEmailSMC21]
22	[entry.FirstLastNameSMC22]	[entry.TitlePositionSMC22]	[entry.OfficePhoneOrExtensionSMC22]	[entry.OfficePersonalEmailSMC22]
23	[entry.FirstLastNameSMC23]	[entry.TitlePositionSMC23]	[entry.OfficePhoneOrExtensionSMC23]	[entry.OfficePersonalEmailSMC23]
24	[entry.FirstLastNameSMC24]	[entry.TitlePositionSMC24]	[entry.OfficePhoneOrExtensionSMC24]	[entry.OfficePersonalEmailSMC24]
25	[entry.FirstLastNameSMC25]	[entry.TitlePositionSMC25]	[entry.OfficePhoneOrExtensionSMC25]	[entry.OfficePersonalEmailSMC25]

Please see the attached Floor Plan document below

Alternatively, you may attach a Microsoft Excel spreadsheet containing data points below by clicking the "Browse" button on the bottom of this form.

1	First / Last Name	Title / Position	Office Phone # or Extension	Office / Personal Email
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Please click the "Choose Files" button below, select your spreadsheet document, and click "Submit".

AJS.tabs.change(jQuery('a[href="#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-4"]'));
//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-4').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});

#	Account User First / Last Name or Group Name	Email Address	Password
Email Account Information		IP: [entry.ClientIP]
1	[entry.FirstLastNameACUser1]	[entry.EmailACUser1]	[entry.Password1]
2	[entry.FirstLastNameACUser2]	[entry.EmailACUser2]	[entry.Password2]
3	[entry.FirstLastNameACUser3]	[entry.EmailACUser3]	[entry.Password3]
4	[entry.FirstLastNameACUser4]	[entry.EmailACUser4]	[entry.Password4]
5	[entry.FirstLastNameACUser5]	[entry.EmailACUser5]	[entry.Password5]
6	[entry.FirstLastNameACUser6]	[entry.EmailACUser6]	[entry.Password6]
7	[entry.FirstLastNameACUser7]	[entry.EmailACUser7]	[entry.Password7]
8	[entry.FirstLastNameACUser8]	[entry.EmailACUser8]	[entry.Password8]
9	[entry.FirstLastNameACUser9]	[entry.EmailACUser9]	[entry.Password9]

We will need access to all current 3rd party web-based email accounts (gmail, yahoo, etc) used internally by staff in order to migrate them to the new email system. Note that this form does not need to be completed if all company email addresses reflect your website domain (e.g. John@FamilyMedical.com).

#	Account User First & Last Name or Group Name	Email Address	Password
1
2
3
4
5
6
7
8
9

Alarm Info:

In order to assist you in case of emergency and to perform technical services after hours when required, we require alarm disarming/arming ability. We have this arrangement with all of our clients.

Alarm Vendor Name:

Alarm Vendor Account Number:

Alarm Disarming Procedure:

Alarm Arming Procedure:

Alarm Building Entrance / Exit Path:

Alarm Building Location:

Alarm Company Support Hotline:

Alarm Disarm Call In Verification Password:

Trash/Recycling:

Outdoor trash/recycling container location:

Trash/recycling container lock key location:

Are trash/recycling containers ever locked?

Ladder Availability:

Ladder Available?

Approximate Height:

Location in Office:

Building Access: (for low voltage cabling)

Under Floor Crawl Space Access Location:

Attic Access Door Location:

Staff Members who Need Remote Access to Office Computers:

First / Last Name:

Practice Management Software Information:

Software Title / Vendor Name:

Account Number:

Administrator Account Username / Password:

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});

Alarm Information	IP: [entry.ClientIP]
Alarm Vendor Name	[entry.AlarmVendorName]
Alarm Vendor Account Number	[entry.AlarmVendorAccountNumber]
Alarm Disarming Procedure	[entry.AlarmDisarmingProcedure]
Alarm Arming Procedure	[entry.AlarmArmingProcedure]
Alarm Building Entrance / Exit Path	[entry.AlarmBuildingEntranceExitPath]
Alarm Building Location	[entry.AlarmBuildingLocation]
Alarm Company Support Hotline	[entry.AlarmCompanySupportHotline]
Alarm Disarm Call In Verification Password	[entry.AlarmDisarmCallInVerificationPassword]
Trash/Recycling
Outdoor trash/recycling container location	[entry.TrashRecyclingContainerLocation]
Are trash/recycling containers ever locked?	[entry.TrashRecyclineEverLocked.label]
Trash/recycling container lock key location	[entry.TrashRecyclineContainerLockKeyLocation]
Ladder Availability
Ladder Available?	[entry.LadderAvailable.label]
Approximate Height	[entry.LadderApproximateHeight]
Location in Office	[entry.LadderLocationInOffice]
Building Access: (for low voltage cabling)
Under Floor Crawl Space Access Location	[entry.UnderFloorCrawlspaceAccess]
Attic Access Door Location	[entry.AtticAccess]
Staff Members who Need Remote Access to Office Computers
First / Last Name	[entry.FirstLastName01]
First / Last Name	[entry.FirstLastName02]
First / Last Name	[entry.FirstLastName03]
First / Last Name	[entry.FirstLastName04]
First / Last Name	[entry.FirstLastName05]
First / Last Name	[entry.FirstLastName06]
First / Last Name	[entry.FirstLastName07]
First / Last Name	[entry.FirstLastName08]
First / Last Name	[entry.FirstLastName09]
First / Last Name	[entry.FirstLastName10]
Practice Management Software Information
Software Title / Vendor Name	[entry.SoftwareTitleVendorName]
Account Number	[entry.AccountNumber]
AdministratorAccountUsername/ Password	[entry.AccountPassword]