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<br />5723 NW 158th Street, Miami Lakes, Florida 33014* Tel.:(305)823-9316 <br />CF: P24214 <br />Page 6 of 6 <br /> <br /> <br /> <br />Client Intake Work Sheet <br /> <br />Primary Contact <br /> <br />Company Name: ______________________________________________________ <br /> <br />Contact Person: ______________________________________________________ <br /> <br />Contact Address: ______________________________________________________ <br /> <br /> ______________________________________________________ <br /> <br /> ______________________________________________________ <br /> <br />Contact Number: ______________________________________________________ <br /> <br />Contact E-mail: ______________________________________________________ <br /> <br />Billing Contact <br /> <br />Company Name: ______________________________________________________ <br /> <br />Contact Person: ______________________________________________________ <br /> <br />Contact Address: ______________________________________________________ <br /> <br /> ______________________________________________________ <br /> <br /> ______________________________________________________ <br /> <br />Contact Number: ______________________________________________________ <br /> <br />Contact E-mail: ______________________________________________________ <br /> <br /> <br />*If different than primary contact, please provide signature below confirming billing responsibility. <br /> <br />________________________________ <br />Billing Contact Signature