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* 1. Email Address

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* 2. Owner's First Name

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* 3. Owner's Last Name

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* 4. Office Phone Number

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* 5. City

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* 6. State

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* 7. Please list all Home Helpers territories that will migrate to ClearCare (City, State, and Franchise Number).

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* 8. Number of Clients Across All Territories

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* 9. Have you and the office seen a ClearCare demo?

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* 10. Ideally, when would you like to begin your ClearCare launch process?

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* 11. What excites you most about ClearCare?

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* 12. Do you have any initial questions for our first call?

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