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Company Name
Contact Person's Name
E-Mail Address
Phone (Optional)Ext
Fax # (Optional)
Co. Address
Co. Address
CITY
STATE ZIP CODE COUNTRY
Type Of Business
The Best Way To Contact Email Me Snail Mail Me Phone Fax

Please Indicate Your Website Design Needs

Type of Website Personal Business Non-Profit Organization

Website Content (Check all that apply)
Company Information
Product/Services Information
Catalog Product/Services
Product/Services Order Form
Customer Info Request Form
Software For Download
Document For Download
Links to Other WWW pages
Sounds
Video Other (describe)
Approximate # of Images Required: 1to5 6to10 more
Approximate # of Web Pages Required 1to5 6to10 more
(example: this form = 1.5 web pages):
Check those which you can provide for your website design.
Printed Material
ASCII text files
Images for Scanning
Images in file format
Audio Tape
Video Tape

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