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NELSON HARDIMAN CLIENT INTAKE SHEET

Please ensure all information is exactly as you would like it to appear in all records and agreements.

Entity

Legal Name(Required)

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address(Required)

The Same

Different

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Business(Required)

Business Phone(Required)

How did you hear about us?(Required)

Primary Contact

Name(Required)

First Last Title

Phone(Required)

Email(Required)

Please tell us briefly about your legal needs:(Required)

Are there any other Contacts (Owners Officers) of the entity?(Required)

Yes

No

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Please add any others if needed.

Are there any outside parties involved? (1)(Required)

Yes

No

Name

First Last

Company Name

Relationship to you/your company

Phone

Email

Are there any outside parties involved? (2)

Yes

No

Name

First Last

Company Name

Relationship to you/your company

Phone

Email

Are there any outside parties involved? (3)

Yes

No

Name

First Last

Company Name

Relationship to you/your company

Phone

Email

Are there any outside parties involved? (4)

Yes

No

Name

First Last

Company Name

Relationship to you/your company

Phone

Email

Are there any outside parties involved? (5)

Yes

No

Name

First Last

Company Name

Relationship to you/your company

Phone

Email

Please add any other outside parties involved here if needed.

Are there any other individuals that needs to receive any of the following.

Client Engagement Agreement?

Invoices/Statements?

Is this contact the same as client?

Yes

No

Name

First Last

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Payor Information

Will statements be paid by you?(Required)

Yes

No

Name

First Last Title

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Name

Phone

Is electronic billing required?(Required)

Yes

No

E-billing provider details

Is this a lawsuit?(Required)

Yes

No

Names of all adverse parties

Name

First Last Title

Company

Name

First Last Title

Company

Has a complaint been filed?

Yes

No

Please provide case number

Other relevant information

I hereby certify that all the information provided in this form is true complete and accurate to the best of my knowledge and belief.(Required)

First Last Title

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