GEM Information Request Form | Senior Care Marketing Experts Helping You Dominate Your Local Area

OVERVIEW: Please complete this form as soon as possible.
In order to launch your new program, we need all questions answered correctly.
Dawn (Dawn@LTCEP.com) will be reaching out to you and offering her assistance, if needed.
In order to complete this form in a timely manner, you will need the following:
- Your logo in a .jpg or .png file- highest quality is the best.
- Upload additional photos of your office, staff, interior, exterior to BASECAMP.
Step 1. Contact Information and GMB Access
This is the contact information for the responsible person who will interface with our team. We also need access to your GMB listing before we can get started.
I have invited DAWN@LTCEP.com and VALERIE@LTCEP.com to be MANAGERS of My Google My Business Listing.*
- YES I HAVE COMPLETED THIS STEP
- NO I HAVE NOT COMPLETED THIS STEP
- WHAT?
Contact Person’s Name*
First Last
This is the main person that will interface with LTCEP
Contacts Person's Phone Number*
This is the main contact person's phone number for interfacing with LTCEP
Contacts Person's Email

This is the main contact person's email address for interfacing with LTCEP

Step 2. Your Official Company Business Address
This is the “citation” for all publishing on all directories and websites ‐ the official business address (exactly how you want it to appear online):
Note: Please also use this format when you publish your info online anywhere, for any reason.
Select your type of agency*
If other please provide your type of agency*
Company Name*
This is the registered name of your company
Company's Local Phone Number*
This is your registered company's direct phone number.
Business E-mail*

This is your registered company's email address
Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

This is the registered address of your company
Have Multiple Offices?
Please add the name, address, phone number, and email for any additional office locations. Please note that ONE GEM PROGRAM is applicable to ONE OFFICE LOCATION.

Step 4. Your Current Website Information
This is the web domain name/url of your website
Your website address (Domain)*

STEP 5. Your Service Area
List your top ten cities or towns that you service in order of priority. We know you service a larger area, but for SEO purposes we need a good place to start.
Remember to list towns and cities, not counties.
Top ten cities or towns that you service in order of priority*
List your top ten cities or towns that you service in order of priority. (these are for use as keyword/search terms for maximum organic traffic volume (ie: Houston, Dallas, Boston etc… These should towns, cities, zip codes.