Welcome To Our
Referral Agent
Lead Submission Form

Please provide the following details:
"*" denotes a required field.

**Agent Information**

Referral Agent Full Name*:
Referral Agent Email*:
Referral Agent Phone Number*:

**Lead Contact Information**

==Primary Contact==
Prospects Full Name*:
Prospects Email*:
Prospects Phone Number*:
Prospects Phone Extension?
Prospects Company Name*:
Prospects Title/Position*:
Prospects Company Website*:
Prospects Country*:
Prospects Time Zone*:
Prospects Business Address:
Prospects City:
Prospects State/Provenience:
Prospects Zip Code:

Prospects Full LinkedIn Profile URL (i.e. https://www.linkedin.com/in/consultingace/):

Secondary Contacts? If others need to be included, please add their information here. Please consider leaving First/Last Name, Title, Email, phone and other information as needed.

**Lead Details**
What Should We Know*? Please provide us with relevant details about your current stage in the process. Include what the organization does and any information you believe is crucial for us to know. Be specific and thorough in your response.

Please describe your relationship with the prospect*:

If known, choose the services they qualify for and may find useful. (Select all that apply): 1. Government Tax & Incentives Recovery Service.2. Merchant Services Credit Card Cost Reduction Service. Includes review of current provider and savings related to switching to a new Merchant Services Provider.3. Accounts Payable Commercial Payments Automation.4. Payroll Optimization and Cost Reduction Service5. Shipping Optimization & Automation Service.6. Telecommunications (internet/phone) Optimization & Cost Reduction Service7. Uniform and Linen Cost Reduction & Recovery Service.8. Medical Underpayment Recovery Service.9. Employment Screening, Drug Alcohol Testing10. Business Loans and Lines of Credit11. Strategic Consulting12. Something Else

Is there a service or services they are most interested? If yes, list it here:

On a scale of 1 to 10, with 10 being the most enthusiastic, what number would you assign to the prospects' interest level?

Tells us about their pain points, why they are interested, and anything else you can share about them or want us to know that can help. (Pain points, interests, goals, hobbies, family, passion projects, books, sports, etc.)

******Optional Per Service Questions******
Providing additional information can be valuable when your prospect expresses interest in a service. While these answers are not mandatory, if you can provide them, please take a moment to fill out the following questions. If not, rest assured that we'll gather these details during the introductory meeting. Your cooperation is greatly appreciated.

== 1 USA Government Tax Incentives and Credits ==
Remember, you should submit this lead to us to ensure you get compensated, but your prospect can use the calculator to see if they qualify and then sign up directly. If you need us or the service provider to speak with them, please provide the following:
Do They Own Property? YesNoI Don't Know
If yes, describe:
About How Many Employees Do They Have?

== 2 Merchant Services & Credit Card Processing Cost Reduction Service ==
Remember, you can submit this lead directly with 3 of the most recent merchant processing statements. If the business experiences seasonal variations include at least one statement from that period.
What is their estimated annual card volume processed.:
Who are they using?

== 3 Commercial Accounts Payable Optimization & Automation ==
(Minimum to qualify: $10 Million or more in yearly accounts payable)
Approximate Annual Revenue:
Approximate Yearly Accounts Payable Spend:
Current ERP System:

== 4 Employee Payroll Optimization & Automation ==
How Many Employees? (250 Minimum):
Approximate Payroll Spend:
Current ERP Software System:

== 5 Shipping Integration & Optimization ==
(Minimum to qualify: ship more than 200 packages a day or spend 2M+/yr)
Current ERP Software System:
Current Shipping Software:
What carrier(s) do they primarily use?
Estimated Annual Shipping Spend:
About how many packages are shipping on average per day?
What do they ship? (check all that apply):ParcelLTL (less than truck load)FTL (full truck load)International ParcelFreightRequire Cold ShipSeasonal Considerations (i.e. shipping flowers to Arizona in the summer or Wisconsin in the winter)Other

== 6 Telecommunications (Internet & Phone) Optimization and Cost Reduction ==
Remember, you can submit this lead directly with 3 of the most recent monthly statements or work to set a meeting.
Who Are They Using:
What Do They Spend:

== 7 Uniform & Linen Rental & Laundry Cost Reduction & Recovery Service ==
Do they rent and/or launder?—Please choose an option—UniformsLinen?Both?
Are their uniform & linen rentals over $100k/yr? YesNoI don't know
If No or don't know, what is the level, and explain:

== 8 Medical Insurance Underpayment Recovery ==
Type of Medical Facility:—Please choose an option—HospitalSurgical CenterERMedical Procedure PracticeA Mix of some or all of the Above:
What are the approximate gross receipts with the top 3 insurers ($2M/yr minimum):

== 9 Employment Screening, Drug & Alcohol Testing ==
Generally, describe what they need:
About how many screens and/or tests do they want to be done per month?
Do they want instant test kits?YesNoI don't know
Do they want someone to come to them to perform tests?YesNoI don't know
Do they want to send their people to a location?YesNoI don't know

== 10 Business Loans ==
Generally describe what they are seeking. If possible list what type, SBA, Equipment, Line of Credit, etc.:

== 11 Strategic Consulting Services ==
Generally, describe what they are seeking and their pain points:
Is there anything else we should know?

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