PBS | New Client Survey

Business Name*
A valid business name. Example: XYZ Physical Medicine Center
Alternative Names
Has your business changed names, or been listed in sites like Yelp, Google Places, Yahoo etc. under a different name? If so, please list them here.
Address*
Street Address Address Line 2 City State ZIP Code
Do you need to add an additional location?
- Yes
- No
Location 2
Street Address Address Line 2 City State ZIP Code
Location 2 Phone
Do you need to add an additional location?
- Yes
- No
Location 3
Street Address Address Line 2 City State ZIP Code
Location 3 Phone
Has your business moved locations or phone numbers in the past 5 years?
- Yes
- No
Previous Address
Street Address Address Line 2 City State ZIP Code
Previous Phone Numbers

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Primary Contact Name*
First Last
Primary Contact Title*
Billing Contact Name
First Last
Main Phone*
Your main business phone number where you would like calls routed.
Alternate Phone
Mobile Phone
Fax
Email*
What email address would you like leads from LocalGiant sent to?*
Have you already registered a domain name for your business?*
- Yes
- No
Website/Domain
If you already have a website, put the URL to your site here. If you have multiple domains, you will be able to add those later on in the survey. Please just enter your primary domain name here. Example: http://www.yoursite.com
Previous Website Addresses
If you've had other websites in the past, what URLs have you used?
Number of Employees*
Please enter a number from 1 to 2000.
Year Established*

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Established Accounts
Please list the Social accounts and Internet Yellow Pages/Directories you have established below.
Business Social Accounts
Please provide the following for any social accounts you have already established for your business. For Example: Facebook, Twitter, foursquare, LinkedIn, etc.
Account Name Login URL User Name Password
Internet Yellow Pages & Directories
Please provide the following for any Internet Yellow Page or Directory accounts you have already established for your business. For Example: BBB.com, YellowPages.com, Yelp.com, Merchant Circle, Judy's Book, CitySearch, Google Places, Bing Local, Yahoo Local, etc.
Account Name Login URL User Name Password
Existing Domain Names
Please provide the following for any Domain Names you have already registered for your business. For Example - Domain Name: yourdomain.com | Registered With: Godaddy | User Name: YourUserName | Password: YoUrPAssWord
Domain Name Registered With User Name Password
Do you currently have a Google Analytics account?*
- Yes
- No
Username/Email
Please enter your Google Analytics Username
Password
Please enter your Google Analytics Password
Do you now, or have you ever had a Google Adwords Account?
- Yes
- No
Username
Please enter your Google Adwords Username/Email.
Password
Please enter your Google Adwords password.

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Short Business Description*
Describe your business in 200 characters or less. Example: The finest italian restaurant in the area.
Long Business Description*
Unique Selling Proposition*
What set's your business apart? Why would a prospective customer choose your business over your competition? Please enter anything here you feel would help us promote your business.
Additional Information
Please enter anything here you feel would help us promote your business.
Favorite Websites*
Please list a few websites you like the look and feel of. This will help direct our design team to make sure your new site is one you love!
Comments
This field is for validation purposes and should be left unchanged.

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Description	License	Date Issued	Date Expires

Business Details

Name	Title	Email Address

Email Account:	Desired Password

Account Name	Login URL	User Name	Password

Account Name	Login URL	User Name	Password