*
First Name:
*
Last Name:
*
Mailing
Address:
*
City:
*
State:
Select A State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District Of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip Code:
*
Company
Name:
*
Email Address:
*
Telephone:
(
)
*
Design Scheme Desired:
*
Click
here to see our design gallery.
Select
Design #1
Design #2
Design #3
Design #4
Design #5
Design #6
Design #7
Design #8
Design #9
Design #10
Design #11
Design #12
Design #13
Design #14
Design #15
Design #16
Design #17
Design #18
Design #19
Design #20
Design #21
Design #22
Design #23
Design #24
Design #25
Design #26
Design #27
Design #28
Design #29
Design #30
Design #31
Design #32
Design #33
Design #34
Design #35
Design #36
Design #37
Design #38
Design #39
Design #40
Design #41
Design #42
Design #43
Design #44
Design #45
Design #46
Design #47
Design #48
Design #49
Design #50
Design #51
Design #52
Design #53
Design #54
Design #55
Design #56
Design #57
Design #58
Design #59
Design #60
Design #61
Design #62
Design #63
Design #64
Design #65
Design #66
Design #67
Design #68
Design #69
Design #70
Design #71
Design #72
Design #73
Design #74
Design #75
Design #76
Design #77
Design #78
Design #79
Design #80
Design #81
Design #82
Design #83
Design #84
Design #85
Design #86
Design #87
Design #88
Design #89
Design #90
Design #91
Design #92
Design #93
Design #94
Design #95
Design #96
Design #97
Design #98
Design #99
Design #100
Design #101
Design #102
Design #103
Design #104
I
will discuss options with desginer
*
Color Schemes Preferred:
*
List the colors of preference
you wish
*
to see incorporated on your web site. They
*
can always be altered after selection.
Keep colors as is on selected layout
*
Logo Title:
*
Usually
Company Name
*
Your Company's Industry:
*
This helps us select the proper
photos
*
to establish your site's theme.
*
Slogan:
*
Additional Design Comments:
*
Home
Page Content:
*
Cut & Paste any text you
may have for the home page. If not sure
*
about the text for the web site, skip
this section and send it to us later.
*
Page Title #2:
*
Ex: Products, Services, Contact
Us
*
Cut & Paste text below:
*
Page
Title #3:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text
below:
*
Page Title #4:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text
below:
*
Page Title #5:
*
Ex: Products, Services, Contact
Us
*
Cut & Paste text below:
*
Page
Title #6:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text below:
*
Page
Title #7:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text below:
*
Page
Title #8:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text below:
*
Page
Title #9:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text below:
*
Page
Title #10:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text below:
*
Page
Title #11:
*
Ex:
Products, Services, Contact Us
*
Cut & Paste text below:
*
Do you currently
have a web site
or a registered domain name:
Yes
No
If
yes, enter web site address:
Ex: www.mysite.com
If
no and would like us to register
your domain name enter it here:
Ex: www.mysite.com
*
Would you like
to add Instant Web Publisher to your site?
Click
here for more about Publisher
Yes
No
If
yes, how many pages:
5 Pages $50/month
+ 1 Page $55/month
+ 2 Pages $60/month
+ 3 Pages $65/month
*
Would you like
us to arrange hosting for your site:
Hosting Fee: $25 per month (plus one time $29.95 setup
fee)- get 2 years for price of one!
Yes
No