Required Fields are Shown in Red & Marked with
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Questionnaire Section
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By providing the following information, you can assist us in serving
you better.
All information you enter here will be used for internal purposes
only. We do not sell or give away customer information to anyone
for any reason. If you would like, please read our
Privacy
Policy.
If you don't have all the information requested below readily
available, don't worry ... we will get to the details later.
However, the more information you can provide us with at this
stage, the better we can evaluate your needs. We will email
you within 72 hours with our response.
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Title
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First Name
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Last Name
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Company/Home based
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Email Address
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Current Site URL
(Web Address)
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Domain Name Wanted
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mybusiness.com or
myfamily.net
(Exclude http://)
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1st Alternate
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sample.com or example.net
(Exclude http://)
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2nd Alternate
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sample.com or example.net
(Exclude http://)
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How many new pages to add?
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(Best estimate for now...)
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New Website Title?
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Launch Date to Target
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(mm/dd/yy)
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Explain in your own words why you want
to redesign your existing web site
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What you
like about your existing
web site?
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What
you do not like about your existing web site?
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Miscellaneous notes
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For graphics, I will...
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Note:
If you can provide web ready graphics on disk, in either .gif
or .jpg (.jpeg) formats, and
snail us this disk or email us
disk content this will help hold your cost down.
If we have to develop new graphics
and artwork, or scan them in,
or manipulate them in any way, it will add to your cost.
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For Content Text, I will...
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What would you like to add on your
new site?
(Check all that apply)
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Guest book(s)
(for visitors to email you their
comments;
visit Guestbook custom
design
or different standard designs here
and here)
Request for Information online form(s)
(visit
Registration Form sample here)
Online Order Form(s)
(visit
samples here
and here)
Printable Order Forms
Secure Order Form(s)/Credit Card Transactions
(visit
a sample here)
Online Shopping Cart(s)
(visit
Shopping Cart samples here
and here
and here)
Sound & Audio File(s)
(businesses should use these sparsely, if at all)
Animated JPG (JPEG), GIF(s)
Video Clip(s)
(businesses should use these sparsely, if at all)
Email
Server-on-Site
(visit
Email Center-on-Site sample here)
Java Applet(s)
Javascript(s)
Web Ring Registration and
Installation
(visit
Web Ring Page sample here)
Link Exchange Banner Network(s)
Installation
(visit
Banner Network Installation sample here)
Chat
Room
(visit Chat Room samples here
and here)
Search
your site engine
(visit samples here
and here)
Page
auto-translation to French, German,
Italian, Portuguese,
and Spanish
(visit
a sample page here)
Page
in Russian inserted to English
speaking site
(visit a page example here)
Other, please contact me to discuss further
(many
other different web
engines-on-site will be added
soon)
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Ordering Services Section
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Account Type
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Business Account
Personal Account
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Note:
If you are seeking services in both areas, select both Account Types above.
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Primary Contact Information
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The information in this section should reflect our
primary contact information for you. This is the
person who will be called or emailed for any issues
or questions dealing with your account.
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Title
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First Name
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Last Name
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Company/Home based
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Address
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City
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State
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Zip Code
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Country
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Day Phone
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+
(
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ext.
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Evening Phone
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+
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ICQ
#
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Fax Line
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+
(
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***
Primary Email
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Secondary Email
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*** Note:
The primary email address is our main contact with you.
Any correspondences will be sent through this address.
Please make sure that you enter a current email address
into this field.
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Billing Information
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The information in this section should reflect our
billing contact information for you. This is the
person who will be called or emailed for any payment
issues or questions dealing with your account.
We accept payment via the Western
Union Money Transfer
service. At this time, we are reviewing
merchant account programs in order to be able to accept
credit cards.
For domain name hosting
& registration
services, credit card payments may be accepted.
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Same as Contact Information
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Title
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First Name
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Last Name
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Company/Home based
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Address
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City
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State
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Zip Code
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Country
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Day Phone
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+
(
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ext.
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Evening Phone
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+
(
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ICQ
#
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Fax Line
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+
(
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Email
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Service(s) Requested
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Check all that apply.
If you are registering a new domain, enter your first choice as
well as at least one alternate (to be used if your first choice
is already registered by another party). Provide only the domain
name (e.g. farlep.net) --
do not include 'http://www'.
Examples: farlep.net or A-Domain-CanBeThisLong.com
[26 positions]
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Register a New Domain with Hosting
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Existing Domain - Transfer to New Host
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Domain Name
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1st Alternate
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2nd Alternate
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Note: We will contact you regarding what you want for your
Account Password as well as how many email addresses
you would like and their respective passwords.
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New Website Design
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Existing Website Redesign
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Number
of Images to Scan
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Existing Site
URL
(Web Address)
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Is there a style you like?
Give URL
(Web Address)
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Choose a Website Maintenance Plan
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Choose a Website Search Engine Submission Plan
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Yearly Contract (Quarterly Submissions)
Single Submission
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How
much Consulting Time is Needed?
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How Did You Find Us
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How did you find us?
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If you have been referred to
us by someone, please enter
their name and/or phone
number or email
address.
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Comments
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Use this section to provide us with any comments, additional
information or special instructions that you would like to
let us know about.
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Comments
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Submit Your Order
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Please re-review the information you have supplied
above. This page has to be checked for errors before
your information is emailed to us.
If you find any errors, please take this time to make
those adjustments now before clicking the "Submit your
Order" button below.
If you would like to totally clear all boxes and start
over, please click the "Clear (start over)" button and
begin again.
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