New Client Intake Form

Thank you for the opportunity to servicing you!

If you prefer to provide this information over the phone, we can gladly do so, however, to save time and to enhance the accuracy of the information, it is always better to use this form instead.

Our New Client setup process is fairly simple:

  1. Fill in the form below.
  2. Once the form is processed and approved on our end, you will get a welcome email to our billing portal, where you will be asked to enter your payment information (Credit Card or ACH).
    1. The email will be sent from our PCI-complied processor “ConnectBooster”.
    2. We require all our customers to have a valid payment method on file.
    3. more information can be found here…
  3. We will Email you our Master Service Agreement for electronic signature. You can preview this agreement here…

Once the above 3 steps are completed, you will be officially registered on our end, and will be eligible to request support from our team!


Additional forms we might request from you:
(you do not need to fill these up, unless asked to do so)

  1. User list collection sheet: Click here
  2. Technical questionnaire: Click here

If at any point you have any questions, please Email us at admin@GallopTechGroup.com, or contact our team via phone. We’re always happy to help !

Company Name *
Company Address 1 *
Company Address 2
Company City *
Company State *
Company Zip *
Company Phone *
Company Alternate Phone
Company Fax
Company Web Site
Company Territory Name *
Company Market Segment *
How to contact you after hours (email, call, etc) *
Company Number of Employees *
Your First Name *
Your Middle Initial
Your Last Name *
Your Title *
Your BILLING Address (Leave blank if it's the same as Company Address)
Your Address 2
Your City
Your State
Your Zip
Your Country
Your Work Phone *
Your Phone Extension
Your Mobile Phone
Your E-Mail Address *
What is your BILLING role? *