Your Name *

Company or Organization Name

Address

City

State Zip

Contact information
Email*
Phone number *
Fax

Type of Organization:
Small Business
Non-profit
Church or Charitable Organization
Other

How soon do you need a website?
30 Days
60 Days
90 Days
6 Months
1 Year or more

Do you need a domain name?
A domain name is your address on the web,
such as www.yourcompany.com.
Yes
No

Do you need email addresses?
ex. yourname@yourcompany.com.
Yes
No

If Yes, how many do you anticipate?
1-5
6-15
16-30
31 or more

What are your goals? In other words, what do you expect to accomplish with a website? Please check all that apply.

Online advertising or advocacy.
Have a place where my users can look up information about my organization.
Provide a way for my customers to order online from my company.

Please use the following box to explain any of these or additional goals:

Use this section to identify people who will be working on this project. Check all that apply:

Project Manager
Subject Matter Expert
Technical Writer
Developer / Programmer
Just Me

Use this section to identify materials already available:

Brochures
Photographs
Logo

Are these materials available electronically?
Yes, on disc or CD
No, hardcopy only