New Client Contact Form

Rapid Response EHC - New Client Contact Form

Please complete all required fields. A formal proposal or contract will follow upon review.

Rapid Response Environmental Health Consulting
3 Morgan Drive, Unit 11, Mount Kisco, NY 10549
(914) 339-5595 | rrenvironmentalhealth.com

Primary Contact

First Name

Last Name

Title / Position

Date of Birth

Email Address

Preferred Contact Method

Business Information

Business / Organization Name

DBA (Doing Business As)

Business Type

Industry / Sector

Business Website

Federal EIN / Tax ID

Business Address

Street Address

City

State

ZIP Code

Mailing Address (if different)

Service & Site Information

Property / Site Address to be Inspected or Serviced

Type of Service Requested?

Preferred Start Date

Project Urgency

Description of Concern or Project Scope

How did you hear about us?

Referral Name (if applicable)

Billing Information

Billing Contact Name (if different from primary contact)

Billing Email

Purchase Order Number (if required by your organization)

Authorizations

Please Click all Boxes that apply to Authorize the following Items

I authorize Rapid Response EHC to contact me via text message

I authorize Rapid Response EHC to contact me via email for updates, reports, and invoices

I am the authorized decision-maker for this property or project

I would like to receive a copy of this completed form for my records

Final Consent

By submitting this form, you confirm that all information provided is accurate and complete to the best of your knowledge. This form is for intake purposes only and does not constitute a contract or agreement for services. A formal proposal or contract will be issued separately by Rapid Response Environmental Health Consulting upon review. For questions, contact us at (914) 339-5595 or visit rrenvironmentalhealth.com.

Please confirm below

I confirm that the information above is accurate and I am authorized to request services on behalf of the business listed.