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First Name: Last Name:
Company Name:
Address: Unit/Suite #
City/Town: State: Zip:
Country:
Phone #: FAX #:
Email:

What is most important to you?
Price Quality Speed Customer Service

What is the size of your company?


How did you hear about us?
Friend Magazine Newspaper Flyer ISP

Do you already have a web site?
Yes No

If yes, what URL:

Please describe the nature of your business:


Please check the pages your web site will need:
Homepage 
Company Profile
Product Line and how many?
Service Line and how many?
News page
Contact page
F.A.Q. page
Support/Download page
Search page
Links page
Employment Page
Showcase page

Do you want to process online transactions? (e.g. VISA, MC, AMEX)
Yes No

Do you want secured server(SSL)?
Yes No

Do you want a database?
Yes No
 Appx. How many items?

Do you want shopping cart?
Yes No

Do you want ActiveX/JAVA script programming?
Yes No
if yes, please state the function:


Do you want custom Video/Audio?
Yes No

Do you want custom animation?
Yes No

Do you want frames?
Yes No

Do you want Flash/Sharkwave?
Yes No

Do you have any custom requests or instructions?


How soon do you needed? (next day cost extra)
next day 1 week 2 week 3 week 1 month

How do you wish to pay for it?
Company check Cashier's check Cash VISA MasterCard

Do you need advertisement/marketing of your site?
Yes No






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