Company Name
Company D/B/A
EIN
Average Monthly Enrollments
Average Debt per Client
Owners Name: (Please have an add button with a dropdown box to add more if they have several owners
First
Last
Phone
Ext
Email
% of Ownership
Department Head Contact Information:
Sales Manager:
First
Last
Phone
Ext
Email
Accounting:
First
Last
Phone
Ext
Email
Legal / Compliance:
First
Last
Phone
Ext
Email
I.T.:
First
Last
Phone
Ext
Email
General:
First
Last
Phone
Ext
Email
Total Number Of Employees
Physical Address
Suite / Unit
City
State
Zip
Mailing Address
Suite / Unit
City
State
Zip
Main Phone Number
Time Zone
Website
Fax
Banking Information:
Bank Name
Type Of Account
Checking
Savings
Routing Number:
Wire Number
Account Number
User Information: (All agents require personal logins)
First
Last
Phone Extension
Permission
- Select One -
Admin
Manager
Sales Agent
Accounting
Marketing