CUSTOMER INTAKE FORM – Lighthouse Internal Forms

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CUSTOMER INTAKE FORM

Your Name

The person filling out this form

ORGANIZATION INFORMATION

Organization Name(Required)

Organization Type(Required)

Law Enforcement

Fire

Dispatch

Corrections

EMS

City

Other

Address(Required)

City(Required)

State(Required)

Zip(Required)

Number of Employees(Required)

Number of Sworn Employees(Required)

PRODUCT INFO

Product(s)

Lighthouse – Core (Grant)

Lighthouse – Core (Paid)

Lighthouse – Pro

LH Add On – Peer Support Pro

LH Add On – Crisis Line

Other (Please Specify)

Other

Internal Code

RED – Paid Plan

YELLOW – Core now, high chance of future paid option

GREEN – Core with low chance of future paid

Term Length

Term Start Date

AGENCY CONTACT

Name(Required)

Title

Email(Required)

Phone(Required)

Add "Other" Contact(Required)

Yes

No

OTHER CONTACT

Name(Required)

Title

Email(Required)

Phone(Required)

BILLING INFORMATION

Billing Information

SAME AS ABOVE

Address

City

State

Zip

Contact Name

Contact Email

Contact Phone

Other Info/Notes

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