Client Intake Form

Higher Purpose Co. is a nonprofit social impact agency based in and serving the Mississippi Delta. Our mission is to create economic opportunity in undeserved communities by providing entrepreneurship education, access to capital, technical assistance, and mentorship. Our goal is to help our clients create successful and profitable businesses for themselves and their community. Please provide the following information to help us better assist the needs of you and your business. 

Name *
Name
Phone *
Phone
Age
Business Stage *
Describe what you do in two sentences.
Please select one of the industries listed below that best describes your business.
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The information submitted in this form is confidential and is intended solely for the signee. This information may also be legally privileged. This transmission is sent in trust, for the purpose of delivery to the intended recipient. Our role is to assist and advise entrepreneurs. We will not make business decisions for you, though we will make recommendations and suggestions as appropriate. These will be based upon our best efforts to apply the experience and resources available to us to assist you in making your own business decisions. The services provided to you are a part of the effort Higher Purpose Co. (HP) and its sponsors to respond to the growing needs of the small business community and to positively affect the economy of the Mississippi Delta. They are not intended to compete with, replace, or be a substitute for services available from the private sector. Clients whose needs can be fully met by private sector practitioners or firms in an affordable manner will be encouraged to use those resources. In consideration of Higher Purpose Co. management and technical assistance, you agree to waive all claims against HP and its constituent institutions, its staff, or any other resources employed by or used in connection with these services. You will also be expected to cooperate with Higher Purpose Co. in its efforts to assure the quality and effectiveness of the counseling services it provides. By submitting your name (Digital Signature) below, you hereby agree to the above terms.