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Name:

Company Name:

Email:

Address

City

State / Province

ZIP Code

Telephone:

1.

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3.

Fax

Service Needed:

Select One New Website Flash Website Wedding Website Anniversary Website Birth Announcement Website Graduation Website Redesign Web Site Flash Intro Flash Banner Flash Presentaion Flash Naviagtion Flash Logo / Vector Graphic Flash Game Static Banner Business Info CD/DVD E-book Software Training Maintenance Plan Other

List Any Additional Services that You're Interested In.

I'd Like the Website Completed:

Select One ASAP Within the Month Within 3 Months Within 6 Months Other

Will You Need Ongoing Maintenance:

Select One Yes No Not Sure

If Yes, How Often?

Select One Once A Week Once A Month As Needed

Please check all pages that you want on your web site:

Additional pages: (view the additional pages section for list of pages)

My Budget Is:

Select One $50 - $250 $250 - $500 $500 - $750 Other

Type of Website:

Select One Business Organization Religious Personal / Family Memorial Other

Type of Business / Organization

My color preferences are:
Color Table Will open in a new window.

I Have A Company Logo / Page Banner

Select One Yes No

Need Us to Create A Logo / Page Banner?

Select One Yes No

I have my site content/text ready:

Select One Yes I have it already written Yes, but I need it edited by You. No, I still need to get that done. No, but can you research & get it started?

Do you need e-commerce solution? (accepting credit card payments through a PayPal shopping cart)

Select One Yes No Maybe Not Sure

I have a domain name:

Select One Yes No

Would you like us to help you purchase one?

Select One Yes No

I'm interested in these domain names:

1.

2.

3.

Do you already have a host for your website?

Select One Yes, I already have a host. No, but I will select a host myself. No, could you recommend & assist?

Please list the URL's of at least three sites that you like the layout or look of:
(They do not need to be in your industry, we're just trying to get an idea of your personal taste)

http://

http://

http://

Please list your reasons for liking those web sites here:

List any other details important to the design of your site.