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Please complete the form below:

Company Phone *Contact Person *Email Do you have a domain name?  Yes  No  If Yes, enter it here Do you have an Internet host?  Yes  No  If Yes, who?

What would you like to have on your web site?

Database    E-commerce    Password protected sections    Frequently updated content    Downloadable files    Other (provide comments below)

If possible, list a few sites you like or would like your site to emulate. (They do not have to be within the same industry. This helps us gauge your expectations.)

Site #1 Site #2 Site #3

When would you like to have a website?

Within the next 1-2 months Now!  We need it immediately Within the next 3-6 months Not sure yet

If you are a referral, please list the client who referred you:

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