| Personal
Information: (Fields marked
with * are mandatory) |
| *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 Email: |
|
| I would
like to be contacted via: |
|
| |
|
| |
Information about
your order:
(Please choose at least one): |
| |
New Website
design (Specify the amount of pages
you would like your Website to be)
|
|
Redesign
of the current Website (Specify URL
below)
|
| |
*Other Information:
|
| |
|
| |
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) |
| |
MPEG video
streaming |
| |
Flash Interactive
Games |
| |
Custom
Software Development |
|
|
| |
Additional
Info
|
| |
|
| *How soon do you need to start the
project?: |
|
| *Time Frame: |
|
| *Please describe the purpose of the
Website and provide any other information
that you feel will be helpful: |
|
| Did
anyone refer you? If yes, who?: |
|
|
|
| |
|
| |
