Business Assessment Information Request

Confidentiality – The information that you about to submit will be held in the strictest confidence. It will only be shared with authorized person within Network Creators™ and IBM® for the sole purpose of assisting in the moving forward towards the “Business Assessment Project”.

This information gathered on this form will not be share by any means to a third party, only by prior authorization.

Name:
Company Name:
Street Address:
Suite #:
City:
State:
Zip:
Phone:
Email:
Business Enity Type:	Corporation L.L.C.PartnershipProprietorship Outside the United States and Canada
Number of locations
Your Industry
Number of Employees
Annual Gross Revenue
#1 Name of Key Decision Maker
#1 Phone Number + Ext
#2 Name of Key Decision Maker
#2 Phone Number + Ext
#3 Name of Key Decision Maker
#2 Phone Number + Ext
Name of CEO/President/Owner
Name of CFO if applies
Name of CIO or IT Director if this applies
Current IT Services Provider if Out Sourced (If this applies)
What are the major goals you wish to attain within the next three years?