General Information:
Name:
*
Company:
Address:
*
Address2:
City:
*
State:
Alaska
Alabama
Akansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachutsetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
*
Zip:
*
E-mail
*
Phone #
*
Fax #
How to Contact?
-Select-
Phone
E-Mail
Fax
Letterhead
How did you find us?
-Select-
Search Engine
Craig's List
Direct Mailing
Business Card
E-mail
Internet Directory
Newspaper Ad
Referral
Trade Show
Search
Engine:
-Select-
All The Web
AOL
Ask Jeeves
Dogpile
Google
Mixcat
MSN
Yahoo!
Other
Keywords:
Do you currently have a website?
What type of website do you require?
What type of services are you seeking? Check all that apply.
Brochure / Information Website Project
Details:
Start Date:
-Select-
Immediately
30 Days
60 Days
90 Days
6 Months
Over 6 Months
Not Sure
End Date:
-Select-
January
February
March
April
May
June
July
August
September
October
November
December
of
2008
2009
2010
Complete this section even if you are selling
products online.
Estimate the number of each of
the following:
Static Pages:
Forms:
E-Mails:
Project Description:
Please
provide as much information as possible.
E-Commerce Website Project Details:
Content & Text:
Photographs:
E-Commerce Product Photographs:
Masthead & Logo:
Layout:
URL's
of Websites You Like the Design (Look & Feel)
URL's of Competitors:
Project Budget
Estimated Website Budget:
-Select-
$500 - $1,000
$1,001 - $1,500
$1,501 - $2,000
$2,001 - $3,000
$3,001 - $4,000
$4,001 - $5,000
$5,001 - $6,000
$6,001 - $7,000
$7,001 - $8,000
$8,001 - $9,000
$9,001 - $10,000
Over $10,000
Over $20,000
Unsure
Estimated Maintenance Budget:
-Select-
Less than $500
$501 - $1000
$1,001 - $2,000
$2,001- $5,000
$5,001- $10,000
$10,001- $20,000
$20,001 - $50,000
$50,001 - $100,000
Over $100,000
Unsure
Additional Information & Comments