* First Name :
* Last Name :
* E-mail Address:
example: you@domain.com
Current Website URL :
(or)
don't have one
Business Name :
(or)
don't have one
* Telephone Number :
[?]
* Your Town/City :
Your State (or Province) :
Your
Country :
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British
Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African
Republic
Chad
Channel Islands/UK
Chile
China
Cocos (Keeling)
Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern
Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
(Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's
Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana
Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peoples Republic of Bangladesh
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts & Nevis
Saint Lucia
Saint Pierre
& Miquelon
Saint
Vincent & the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South
Georgia & South Sandwich Island
Spain
Sri Lanka
Sudan
Suriname
Svalbard
& Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
The
Democratic Republic of Congo
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos
Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United
States Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands,
British
Virgin Islands,
U.S.
Wallis & Futuna
Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
OTHER
What is the purpose of your website?
Please Select One
Information
site overviewing my business/service
To sell products
online
To sell services
online
To
provide Information to my customers
To
have a member only subscription site
Other (Specify in Comments Section)
* Please
describe what Web Services you need and/or goals of your
website :
Do
you have a Company Logo?
Please Select One
Yes,
I have a logo you can use for the site
Yes,
but I want a logo redesign - please quote
Yes,
but I want an animated version for site - please quote
No,
I don'thave a logo - please quote for a static one
No,
I don'thave a logo - please quote for a static and animated
one
No, I don't want
a logo
I'm not sure
Can
you provide written text content for the site?
Yes
Not Sure
No,I need you to write text content for the pages
Do you need Web Hosting?
Yes
Not Sure
No, Already have hosting
No, I'll get my own hosting
Do you
need a Domain Name?
Yes
Not Sure
No, Already have hosting
No, I'll get a domain myself
Please
list any competitor websites you Like :
What's
the size of your company :
Small
Medium
Large
Not a Company
How
long have you been in business?
Please Select One
New Business
Just Started
Been in Business
1-2 Years
Been in Business
3-5 Years
Been in Business
5-10 Years
Been in Business
10+ Years
Not a Business
* Please
estimate your budget range:
Please Select One
$500-$1,000
$1000-$2,000
$2000-$4000
$4,000-$6,000
$6,000-$8,000
$8,000-10,000
$10,000 Or More
(Please be realistic so that we may better serve you) [?]
Please
include any questions or comments here :
How
did you find our site?
Please Select One
Google Search
Yahoo
MSN
Alta Vista
Ask Jeeves
Lycos
HotBot
Overture
Friend Referral
A Directory
Link from other site
Other
Other:
How
should I contact you?
Email
Telephone
Either
Additional Information
If your project will involve programming, ecommerce, user registration or database development please try and provide some additional information here.
What operating system does your web server use?
Please Select One
Not Sure- i'm flexible on this
Windows 2000/NT
Windows XP/Professional
UNIX/LINUX
If programming is required, do you have a preferred programming language?
Please Select One
Not Sure- i'm flexible on this
PHP
ASP
ASP.Net
What is the preferred database, if required?
Please Select One
Not Sure- i'm flexible on this
MS SQL
MySQL
Access
Oracle
Simple text databse is fine