Client Intake New Client Intake Form Sales completes Sections A-E at time of sale. Section F auto-flags above $20,000 CapEx. A. Account & Contact DetailsBusiness UnitPremierFresh & EasySouthwestLarsenSite Visit DateSite visit must be completed prior to form submission. Date Format: MM slash DD slash YYYY Sales RepHeatherMartyJasonJohnOtherAccount / Customer NameSite AddressSite Contact NameContact PhoneContact Email End MarketMultifamily/ApartmentSchoolManufacturingCar DealershipHealthcareOfficeOtherReferral SourceExisting CustomerCold OutreachInboundOtherContract Start Date Date Format: MM slash DD slash YYYY Target Install Date Date Format: MM slash DD slash YYYY B. Service & Commercial TermsService Type(s) - select all that apply Markets Vending Coffee Water Pantry Other Service (specify)Number of Vending/Market LocationsEquipment Needed - Quantity & Type/ModelBeverage CoolerFresh Food CoolerAmbient MachineFreezerCoffee MachineVending MachineOther EquipmentEquipment QualityNewRefurbish ExistingPurchase UsedRental Fee Charged to CustomerYesNoUnder ContractYesNoContract Length MonthsCommission Paid to CustomerYesNoCommission PercentN/A5%10%15%20%25%Subsidy Provided to EmployeesYesNoSubsidy DetailsC. Install & Site DetailsEmployees Onsite CountNumber of ShiftsOpen to PublicYesNoAccess Service Hours24/7 - Key Fob AccessBusiness Hours OnlyOtherKiosk Market TypePicoMarket+Pico PlusMiniN/AConnectivityOptConnectData LineWiFiN/APower Outlets CountFixtures NeededIs there a coffee program on-site?YesNoIf yes, who manages coffee program?Water Line PresentYesNoSpecial Instructions Dietary NeedsD. CapEx / FundingAnnual Revenue EstimateEquipment Purchase RequiredYesNoDescription of New Equipment NeededEstimated Purchase CapEx AmountE. Approval ChecklistEmployees Onsite > 100? YesEmployees Onsite > 100? NoMultiple Shifts? YesMultiple Shifts? NoWorkforce TypeIn PersonHybridLocation within 50 Miles of WarehouseYesNoServiceable on Existing RouteYesNoF. CapEx Escalation - Required if Estimated CapEx exceeds $5,000⚠ ESCALATION REQUIRED - CapEx exceeds $5,000 thresholdNot required - CapEx under $5,000Implementation Cost Build-UpEquipment Purchase Cost TotalTotal Equipment UnitsShipping Cost?How much will shipping be for the requested units?Total Implementation (Unit + Shipping)Deal Terms and Sign-OffDeal Risk Urgency Notes
