Request for Proposal

Please enter the following information:

Organization Name:
Street Address:
City:
State:
Zip:
Website Address:
Type of Business:
Number of Employees:
Multiple Locations:	Yes No
If yes, where are they located?
Does the company have an existing EAP?	Yes No
Session model requested: (you may request pricing on more than one)	1-3 1-5 1-6 1-8
Interest in additional services: *Some services are included in standard EAP proposals and contracts.	Organizational Development Work-Life Corporate Health Programs Crisis Management/Debriefing* Risk Management	Corporate Training & Development* Elder Care Planning Substance Abuse Program Management/DOT Compliance On-line Services*
Other information that would be helpful:
Proposal needed by what date:
Program implementation date:
How did you learn about Southwest EAP?	Brochure/Marketing Word of mouth	Online search Previous work with company

Contact Name:
Title:
Email:
Phone Number:
Fax Number:

If the contact above is a Broker, Consultant or TPA, please complete the following. We will only make contace with your client company if requested by you or your company.
Company Name:
Address:
City:
State:
Zip:
Any additional requests:
Thank you for the opportunity to provide services to your company.