GBPO Service Request Form

Email*

Business Name and D/B/A (if applicable; e.g., Acme, Inc. d/b/a Acres Grocers)*

Month and Year Business Established (MM/YYYY)*

Business' Main Phone Number (e.g., 703.555.2121)*

Business' Main Physical Address (e.g., 123 M Street, Suite 456, Wherein, VA 22314; N/A if none)*

Number of Physical Locations (e.g., 1)*

Business' Web Address (N/A, if none)*

Business' Google Verification Status (i.e., Verified or Unverified)*

Contact's First and Last Name, and Title (if not the owner(s); e.g., Bill Harris, Manager)

Average Monthly Transactions/Sales (e.g., 1000)*

Average Monthly Revenue (e.g., $5000)*

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