CLIENT INTAKE FORM

Date ___________________________ Client File Number

Name __________________________ Tribal Ancestry/Band

Status o Non-Status o Métis o Inuit o None o

Age ( ) DOB Youth (18-35?) Yes o No o

Address City _________________

Postal Code Home Phone ___ Fax

Work/Cell/Message Phone # Email

Referred By Marital Status Spouse

Have you been on Employment Insurance? Yes o No o

Presently o Start date Past 3 years o Maternity past 5 years o

Company Name Registered? Yes o No o

Business Start-Up o Business Expansion o Business Buy/Sell o

Type of Business:

Manufacture o Retail o Service o Description

Funding Source:

Forestry o Youth o FCF o ABC o Other o

Full Time Part Time Seasonal

Projection of Jobs Created __________ __________ __________

Projection of Jobs Maintained __________ __________ __________

Mandatory Equifax Credit Check on client: Done o Needs to be done o

By signing below, I authorize the Northeast Aboriginal Business Centre authority to collect relevant information to assist with the development of my business plan, cash flow and pursuit of funding sources.

Client Signature: Date: