Become a Client:

Individuals

	Section 1 – Individual Client
First Name *
Middle Initial
Last Name *
Email *
Home Address *
City *
Province *
Postal Code *
Home Phone No. *
Mobile Phone No.
Home Fax No.
Occupation *
Business Name *
Business Address *
City *
Province *
Postal Code *
Business Phone No. *
	Section 2 - About Your Business
Website
Industry/Sector *
Please provide a short description of your Business Purpose & Mission *
Please describe your product(s)/service(s) and the challenges they address *
Date of business formation *
Annual revenue from preceding year *
Projected revenue for current year *
3rd Party financing sources to date
No. of employees *
Please list your biggest current business challenges *
	Section 3 – Desired Service
How Did You Hear About Us?	FriendNetworkingLinkWebWeb
Please provide a short description of the service you desire. *
Please enter the 4 letter security code you see in the box.

*Please note that Positive Impact Law Group accepts the following methods of payment for services: Credit Card, Debit, Money Order, Cheque and Cash.  If you retain Us for any matter and choose to pay by Money Order Cheque or Cash, we will need to take extra steps to verify your identity.