ROUTING:          Director            [Partner 1]            [Partner 2]            [Partner 3]            [Partner 4]

 

Completed By:                                 Date:                                                          Client Number:                                    Engagement Number:      

Status:       Active Client        Active Prospect       Active Referral Source   Engagement Description:                                                                 

                                                        (Check one)                                                    Retain Files Indefinitely?                        Yes                      No

                               NAME and ADDRESS                                                                                 MAILING ADDRESS (if different)

                                                                                                                                Attention Name:                                                                                

Client Name:                                                                                                        Client Name:                                                                                       

Address Line One:                                                                                              Address Line One:                                                                             

Address Line Two:                                                                                              Address Line Two:                                                                             

Address Line Three:                                                                                           Address Line Three:                                                                          

City:                                            State:              Zip:                                             City:                                            State:              Zip:                            

Telephone #:                                        Fax #:                                                     Email Address:                                                                                   

Client Type*:                             Fiscal Year End:                                   Department*:     C       F       N SIC Code**:                                       

                                                                                                                                                        (Check one)

Federal ID#:                                            Social Security #:                                                       Spouse Social Security #:                                         

Primary Director:             Bill Manager:                Tax Reviewer:              Client’s Annual Revenue*:            Client’s # of Employees*:         

Codes for Phone #’s:

C = Cell                   H = Home               W = Work               P = Pager                F = Fax

Mailings:

1 = Newsletter – Quarterly Think Black Ink                         3 = Planning Guide                               5 = Special Year-End Mailing (calendar, card, etc.)

2 = Newsletter – Quarterly Technology                               4 = Payroll Deposit Schedule               6 = Newsletter – Family Business Today

Employee Responsible for Acquiring Client:                                                 Referral Responsible for Acquiring Client:                                    

Referred How*?                                                                                                                                                                                                                  

Law Office:                                                                               Attorney Name:                                            Phone #:                                                   

Bank:                                                                                          Banker Name:                                              Phone #:                                                   

Comments:                                                                                                                                                                                                                          

*Please refer to the back of this form for these codes.

**SIC Code:  Please refer to Consolidated SIC Code Listing which is located in Outlook Public Folders under Forms.

Engagement Fee:                                                              

100         Agriculture

1000       Mining

1500       Construction

2000       Manufacturing

4000       Transportation

4800       Communications – Radio/TV

4900       Public Utilities

5000       Wholesale Trade

5200       Retail Trade

6000       Banks – Depository & Non-Depository

6100       Credit Unions

6200       Security & Commodity Brokers

6300       Insurance – Carriers, Agents, Brokers, Service

6500       Real Estate

6700       Holding Companies, Trusts, Investing

7300       Services – Business

7900       Services – Other

8000       Services – Medical/Dental

8100       Services – Legal

8200       NPO – Education/Schools

8300       NPO – CAP Agencies/HS

8400       NPO – SDA

8500       NPO – Community-Based Organizations

8600       NPO – Membership Organizations/Trade Associations

9100       Public Administration/General Government

99999    Individuals