Web Design Request Form

Web Site Information

Enter your web site address (ex. www.your-name.com):

Do you have current hosting provided for your web site? yes no

Please select the catergory that describes your business:
:
Apparel Accessories Business Services Vehicles Catalogs Computers Electronics Gardening Household Products Gov't Services Non-Profit Org. Travel Financial
Entertainment Dolls Books Other

If you selected other, enter your type of business here:

Web Design Information

Choose the type of web site design you're interested in:
Internet Banner
Personal Home Page (up to 3 pages)
Economy Business (up to 8 pages)
Business eCommerce (up to 20 pages)
Business Professional (25 pages or more)

Please select your web design preferences for your website:

(GIF) Pictures
JPEG
CGI Scripting
Form Mail
Flash technology
hyperlinks
shopping cart
data base
frames
logo
website submission
web hosting

Describe in your own words the type of webdesign you're looking for.

List the types of items you will display on your website?

Do you have your own pictures and graphics for your new web design? yes no


Please describe the color schemes for your new website design in 50 words or less:

Please use this section to describe your company, service provided and/or sales information:

Business eCommerce Information

Do you have an existing merchant account? yes no
If yes, enter the name of your credit card processing company

How do you prefer to process your orders? offline, email encrypted realtime processing mail orders phone orders

Email: Contact Person:

Name of Business:

Type of Business:

Business Address:

City, State, Zip:

Shipping Address:

City, State, Zip:

Contact Phone Number:

Fax Number: