| Personal Information: (*Required
fields) |
| First Name * |
|
| Last name * |
|
| Organization (Co. Name) |
|
| Address 1 |
|
| Address 2 |
|
| City |
|
| State/Province |
|
| Zip / postal code |
|
Country
|
|
| Phone Number * |
(please include area code) |
| Fax number (optional) |
|
| Contact E-mail * |
|
| |
|
| |
Information about your order:
(Please choose at least one): |
| |
New web site design (Specify
the amount of pages you would like your web site to be)
|
|
Redesign of the current Web site
(Specify URL below)
|
| |
Other Information
(please specify):
|
| |
|
| |
Please select features and services you
will require: |
| |
Logo Design |
| |
Flash Animation/Presentation/Intro |
| |
Interactive Features (Form Mail) |
| |
Site Maintenance (after completion
of project) |
| |
Banner Design |
| |
Database Programming |
| |
Custom Web Programming |
| |
HTML Newsletters |
| |
Custom Script Design (cgi, java,
perl, etc) |
| |
Custom Software Development |
| |
Shopping Cart |
| |
Additional Info:
|
| |
|
| How soon do you need to start
the project?: * |
|
| Time Frame: * |
|
| Please describe
the purpose of the Web site and provide any other information
that you feel will be helpful: |
|
| Did anyone refer you? If
yes, who? |
|
| |
|
|
|
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