In-Take Lead/Sales Form In-Take Form SectionName First Last What state is the salon in?How did you hear about Aerovex? Have you been to our website?What prompted your call today?What's the name of your (or the) salon?Is your salon open already?YesNo[ONLY if answered NO above] When are you planning to open? Date Format: MM slash DD slash YYYY What type(s) of services do/will you offer?How many mani and/or pedi stations, keratin chairs, or lash beds?On average, how many services will be done every week?Are there any concerns about any unhealthy symptoms? (Use options below to give examples)Constant headacheItchy eyesSore throatsOtherWhat type of air purification systems are you using to get rid of the dust, vapors & odors?What is the size of the salon space (just approx sq ft)?How high are the ceilings? (ex. 8, 9, 10 ft)Would you like to speak to Keith, our salon code expert?YesNo (If no, emphasize it could help them save $$)No, just need to place an order (they already spoke with Keith)PhoneWhat's your best email Notes about prospectWhen will you need delivery? (If they're hesitant to say, "We just need to know to prevent any delays")Products | Quantity | Pricing | CommentsShipping Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Discounts GivenFreight Discount - Aerovex Website Pkg Discount - Consultant Discount -Shipping CostBe sure to get cost from Lucas if shipping is palletized.Total (after discounts + shipping)Filter/Carbon Replacement Schedule 4 Months 6 Months (most popular choice) 12 Months Choose Later (Reiterate benefits of scheduling now) (HELPFUL TO SAY TO CUSTOMER) Three Reasons to Schedule at time of purchase... #1 - Extends their warranty from 1 year to 3 or 5 years (depending on system) #2 - They will earn Loyalty Rewards Points they can use toward future purchases #3 - It ensures their business continues to run smoothly because it prevents them from forgetting their replacement.Payment Info & Special Billing Instructions(Add PayPal email address if applicable) Full Name on Credit Card Credit Card Type (Do NOT type last 4 #'s here, send in separate email) CC # Exp Date CCV Code Billing Address (if different than shipping)Payment Plan*Do they want to make a full payment, partial payment, or use Paypal, etc.?Who is filling out this form?* First UntitledFirst ChoiceSecond ChoiceThird Choice
