Client Engagement Form

First Name

Last Name

Email Address

Phone Number

Address

City

Postal Code

Do you identify with any of the following groups? Your response is used solely for internal reporting purposes and will not impact your ability to receive support from Community Futures Middlesex. Do you identify with any of the following groups? Your response is used solely for internal reporting purposes and will not impact your ability to receive support from Community Futures Middlesex. Francophones Indigenous Peoples LGBTQ2+ Members of Official Language Minority Communities Newcomers to Canada Persons with Disabilities Social Enterprises Visible Minorities Women Entrepreneurs Youth Entrepreneurs (under 40 years of age) None of the above

Business Name (if applicable)

Business Address (if applicable)

Business City (if applicable)

Business Postal Code (if applicable)

Which of the following best describes the current phase of your business? Which of the following best describes the current phase of your business?Start-upMaintenance or Expansion

Which of the following sectors best describes your business? Which of the following sectors best describes your business?AgricultureConstructionEnergyHealth CareManufacturingNon-ProfitRetailServiceTechnologyTourism

Please describe your business or business idea.

When did you start operating your business? (if applicable)

In which lower-tier municipality does/would your business reside? In which lower-tier municipality does/would your business reside?Adelaide MetcalfeLucan BiddulphMiddlesex CentreNewburyNorth MiddlesexSouthwest MiddlesexStrathroy-CaradocThames CentreUnsure

Are you interested in our business financing services? Are you interested in our business financing services?YesNoUnsure

Are you interested in our business consulting services? Are you interested in our business consulting services?YesNoUnsure

Please specify your business consulting needs.

How did you learn of Community Futures Middlesex? How did you learn of Community Futures Middlesex? Advertising Board Member Referral Client Referral Google Search Government Referral Other Community Futures Referral Professional Referral (i.e. banker) Social Media Staff Member Referral Website Other

Please specify how you learned of Community Futures Middlesex.

I hereby declare that the information provided is correct.