New Client Setup Form

COMPANY INFORMATION

Client legal name for contract:

Address:

City, State, Zip:

Contact name:

Email:

Phone number:

Client industry:

BILLING ADDRESS (If different from above)

Address:
PREFERRED METHOD OF BILLING (Please check box)

Mail

Other (please explain)

Email
CONTRACT INFORMATION
Start date: 7/1/2016

Month to month after end date? Yes (Standard) No

End date: / /2016

Optional dates:

Fee and compensation terms: $_________ per month

Government Relations/Lobbying: Yes

No

Lobbying locations:

BUSINESS UNIT (Please choose from drop down menu, if more than one use additional drop down for each unit)
Please Select a Unit:

Please Select a Unit:

Please Select a Unit:

STAFF / REVENUE ALLOCATION / DIRECT CLIENT EXPENSES

Did a Mercury employee bring in this client (Originator)? Yes No If yes, employee name:
What Mercury employee will be the lead rep in charge of this client and billing (Lead)?
What Mercury employee(s) will be working on this client?
Please note any special revenue allocation here:
Will there be Subcontractors or 3rd party expenses? Yes
No
Please specify:
Internal referral fee? 18% 12% 10% No
Specify business unit:
REVENUE CLASSIFICATION:
(Please select classification based upon services Mercury will be providing)

Please Select a Classification:

Please Select a Classification:

Please Select a Classification:

IF REVENUE CLASSIFICATION IS NOT LISTED, PLEASE INDICATE IN TEXT BOX: Click here to enter text.

KM Signature & date:

____/____/2016

Kieran Mahoney

324486127

Please email completed form to mulbrich@mercuryllc.com (Rev 07012016)

July 21, 2016