Common Ground Client Intake form

Common Ground Collective

New Client Intake Form
Thank you for your interest in becoming a CGC client! Please take a moment to fill out this form completely so we can get to know you better and have an idea of how we can best support you with our services. If a question does not apply indicate N/A.
Once submitted a representative will contact you within 5 business days to discuss the next steps.

Thank you and we look forward to growing with you!
Applicant's Name

First NameLast Name
Business Name
Organization Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
What services are you interested in? Please check all that apply.
Mobile Farming Services

Other
Administrative Services

Other
Education

Other
Client Demographics
Ethnicity

Other
Household Size
Household Income (Answer if you'd like to be considered for sliding scale payment.)
Property Location

Other
Property Size

Other
Is the property currently in production?
How did you hear about us?(Referrals or articles check other and type in name of business, person or publication.)

Other
Any other questions or concerns?
Should be Empty:

Common Ground Collective