Whitelabel / Cobranding Intake Form
Thank you for your interest in partnering with BCA Culture.
Please complete the form below so we can better serve you.
Your First and Last Name
Company Name
Organization Type
Private Company
Public Company
Government Agency
Please describe your organization
Primary Contact Email
Primary Contact Phone Number
Website
Number of Current Clients
The number of current clients that will be enrolled into BCA Culture right away
Number of Projected Clients over the next 12 months
The number of clients that will be enrolled over the next 12 months
What are you looking to accomplish for your organization with this partnership?
What would a successful partnership look like for you?
What is your budget range to get started?
$8k-$15k
$15k-$25k
$25k-$50k
$50k-$75k
$75k-$100k
$100k-$200k
$200k+
How soon are you looking to start?
As quickly as possible
1 to 2 weeks
2 to 4 weeks
1 to 2 months
2 to 3 months
3 months+
Are you the primary decision maker?
YES
NO
Who else is going to be involved in making the final decision?
Preferred Branding Option
Co-Branded with BCACulture.com
Fully Branded to your Company
Will you be charging your clients directly for access?
YES
NO
Are you looking to make a profit from reselling our services?
YES
NO
Do you currently have your own merchant account to process client payments?
YES
NO
Not applicable
Please list merchant accounts used if applicable
Who referred you to BCA Culture?
Please enter the name of the person that referred you to us if applicable
Submit
