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Date:

Client Name:

Tax ID#:

Business Hours of Operation:

Lunch Period From:

Lunch Period To:

Preferred Payment Method:



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

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Owner/Executive Owner/Executive Owner/Executive

Owner/Executive Owner/Executive Owner/Executive

Owner/Executive Owner/Executive Owner/Executive

Office Manager Internal Technical Contact Internal Billing Contact



Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

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Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

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Staff Member Contact 34


Staff Member Contact 35



Staff Member Contact 36



Staff Member Contact 37



Staff Member Contact 38


Staff Member Contact 39


Staff Member Contact 40


Staff Member Contact 41


Staff Member Contact 42


Staff Member Contact 43


Staff Member Contact 44


Staff Member Contact 45


Staff Member Contact 46


Staff Member Contact 47


Staff Member Contact 48

Staff Member Contact 49


Staff Member Contact 50


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We will need access to all current email accounts used by staff in order to migrate them to the new email system. Please provide information for all current email accounts in use below.

Account User First & Last Name or Group Name
Email Address
Password
1

2

3

4

5

6

7

8

9






BusinessInformationForm

AdministrativeForm

----


StaffMemberContactForm



EmailAccountForm

BusinessInformationForm

AdministrativeForm

StaffMemberContactForm

EmailAccountForm




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.



Trash/Recycling:



Ladder Availability:



Building Access: (for low voltage cabling)

Staff Members who Need Remote Access to Office Computers:

Practice Management Software Information:















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$("#custom-overlay").css('left','0');
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$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
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$("#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
Client Name[entry.ClientName]
Date[entry.DateFilled]
TaxID#[entry.TaxID]
BusinessHoursOfOperation[entry.BusinessHoursOfOperation]
LunchPeriodBegins[entry.LunchPeriodBegins]
LunchPeriodTo[entry.LunchPeriodTo]
PreferredPaymentMethod[entry.PreferredPaymentMethod]

Administrative Contact Information

First / Last NameTitle / PositionCell Phone #Home Phone #Office Phone # or ExtensionOffice / Personal Email
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]

Staff Member Contact Information
#First / Last NameTitle / PositionOffice Phone # or ExtensionOffice / Personal Email
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]
26[entry.FirstLastNameSMC26][entry.TitlePositionSMC26][entry.OfficePhoneOrExtensionSMC26][entry.OfficePersonalEmailSMC26]
27[entry.FirstLastNameSMC27][entry.TitlePositionSMC27][entry.OfficePhoneOrExtensionSMC27][entry.OfficePersonalEmailSMC27]
28[entry.FirstLastNameSMC28][entry.TitlePositionSMC28][entry.OfficePhoneOrExtensionSMC28][entry.OfficePersonalEmailSMC28]
29[entry.FirstLastNameSMC29][entry.TitlePositionSMC29][entry.OfficePhoneOrExtensionSMC29][entry.OfficePersonalEmailSMC29]
30[entry.FirstLastNameSMC30][entry.TitlePositionSMC30][entry.OfficePhoneOrExtensionSMC30][entry.OfficePersonalEmailSMC30]
31[entry.FirstLastNameSMC31][entry.TitlePositionSMC31][entry.OfficePhoneOrExtensionSMC31][entry.OfficePersonalEmailSMC31]
32[entry.FirstLastNameSMC32][entry.TitlePositionSMC32][entry.OfficePhoneOrExtensionSMC32][entry.OfficePersonalEmailSMC32]
33[entry.FirstLastNameSMC33][entry.TitlePositionSMC33][entry.OfficePhoneOrExtensionSMC33][entry.OfficePersonalEmailSMC33]
34[entry.FirstLastNameSMC34][entry.TitlePositionSMC34][entry.OfficePhoneOrExtensionSMC34][entry.OfficePersonalEmailSMC34]
35[entry.FirstLastNameSMC35][entry.TitlePositionSMC35][entry.OfficePhoneOrExtensionSMC35][entry.OfficePersonalEmailSMC35]
36[entry.FirstLastNameSMC36][entry.TitlePositionSMC36][entry.OfficePhoneOrExtensionSMC36][entry.OfficePersonalEmailSMC36]
37[entry.FirstLastNameSMC37][entry.TitlePositionSMC37][entry.OfficePhoneOrExtensionSMC37][entry.OfficePersonalEmailSMC37]
38[entry.FirstLastNameSMC38][entry.TitlePositionSMC38][entry.OfficePhoneOrExtensionSMC38][entry.OfficePersonalEmailSMC38]
39[entry.FirstLastNameSMC39][entry.TitlePositionSMC39][entry.OfficePhoneOrExtensionSMC39][entry.OfficePersonalEmailSMC39]
40[entry.FirstLastNameSMC40][entry.TitlePositionSMC40][entry.OfficePhoneOrExtensionSMC40][entry.OfficePersonalEmailSMC40]
41[entry.FirstLastNameSMC41][entry.TitlePositionSMC41][entry.OfficePhoneOrExtensionSMC41][entry.OfficePersonalEmailSMC41]
42[entry.FirstLastNameSMC42][entry.TitlePositionSMC42][entry.OfficePhoneOrExtensionSMC42][entry.OfficePersonalEmailSMC42]
43[entry.FirstLastNameSMC43][entry.TitlePositionSMC43][entry.OfficePhoneOrExtensionSMC43][entry.OfficePersonalEmailSMC43]
44[entry.FirstLastNameSMC44][entry.TitlePositionSMC44][entry.OfficePhoneOrExtensionSMC44][entry.OfficePersonalEmailSMC44]
45[entry.FirstLastNameSMC45][entry.TitlePositionSMC45][entry.OfficePhoneOrExtensionSMC45][[entry.OfficePersonalEmailSMC45]
46[entry.FirstLastNameSMC46][entry.TitlePositionSMC46][entry.OfficePhoneOrExtensionSMC46][entry.OfficePersonalEmailSMC46]
47[entry.FirstLastNameSMC47][entry.TitlePositionSMC47][entry.OfficePhoneOrExtensionSMC47][entry.OfficePersonalEmailSMC47]
48[entry.FirstLastNameSMC48][entry.TitlePositionSMC48][entry.OfficePhoneOrExtensionSMC48][entry.OfficePersonalEmailSMC48]
49[entry.FirstLastNameSMC49][entry.TitlePositionSMC49][entry.OfficePhoneOrExtensionSMC49][entry.OfficePersonalEmailSMC49]
50[entry.FirstLastNameSMC50][entry.TitlePositionSMC50][entry.OfficePhoneOrExtensionSMC50][entry.OfficePersonalEmailSMC50]

Email Account Information
#Account User First / Last Name or Group NameEmail AddressPassword
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]

Alarm Information
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]
Trash/recycling container lock key location[entry.TrashRecyclineContainerLockKeyLocation]
Ladder Availability
Ladder Available?[entry.LadderAvailable]
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]