Bassett Consulting - Professional Regulatory Compliance Services
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Client Information Sheet


Interested in becoming a client? To get started, please fill out and submit our client info sheet.

Initial consultation is free of charge and you are under no obligation.
1. Please tell us a little about yourself.
Contact Full Name:
Contact Email:
Office Phone: Office Fax:
Alternate contact number(s):
2. Please tell us a little about your Company.
Company Name:
Company Website:
State of Incorporation:
Date of Incorporation:
Fictitious Name(s) or DBA's:
Street Address:
City: State: Zip:
*Billing Address (If different from above):
Street Address:
City: State: Zip:
3. Please answer all of the following questions:
Name of your designated compliance individual (if applicable):
Compliance individual's contact number/extension (if applicable):
Alternate contact number(s) (cell phone, etc):
Is your company licensed as a Commerical Telephone Seller in the State of Florida?
Not Sure
If "Yes," list your Florida Commerical Telephone Seller's License #:
What product(s), service(s), or program(s) will you solicit?
What states will your company be making telephone solicitation calls to?
(Check all that apply)
All States
4. Please check any services below that you would be interested in:
(Check all that apply)
Complaint handling & response assistance
Florida Registered Agent / Certificate of Authority
Merchant Account Services
BPO (Business Process Outsourcing) Services
Database systems design & maintenance
Telephone systems / technology
Other States Certificate of Authority
Do Not Call List / Assistance
Website Design & maintenance

5. How did you hear about us?

Referral (Business / Company)
--- Name of Business / Company:

Referral (Personal Friend)
--- Name of Personal Friend:
Internet Search Engine (,, etc)
Web Advertisement (Craigslist, Yahoo!, etc.)
Web Yellow Pages (,


Thank you for providing this information.
We look forward to serving you!

Bassett Consulting, LLC > Forms > Client Information Sheet