CUSTOM WEB DESIGN PROJECT FORM

INCOMPLETE FORMS WILL BE DISCARDED

FIRST NAME

LAST NAME

TITLE

COMPANY

STREET ADDRESS

CITY

Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Africa Armed Forces America Armed Forces Canada Armed Forces Europe Armed Forces Pacific Armmd Forces Middle British Columbia California Colorado Connecticut Delaware District of Columbia Federated States of Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana N.W.T. Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Isl Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Island Virginia Washington West Virginia Wisconsin Wyoming Yukon Outside US - Canadian Territories
STATE OR PROVINCE

POSTAL ZIP CODE

Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaidjan Bahamas Bahrain Banglades Barbados Belarus Belgium Belize Benin Bermuda Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian O. Terr. Brunei Darussalam Bulgaria Burkina Faso Burundi Buthan Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos (Keeling) Isl. Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Czechoslovakia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Estonia Ethiopia Falkland Isl.(Malvinas) Faroe Islands Fiji Finland France France (European Ter.) French Southern Terr. Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain (UK) Greece Greenland Grenada Guadeloupe (Fr.) Guam (US) Guatemala Guinea Guinea Bissau Guyana Guyana (Fr.) Haiti Heard & McDonald Isl. Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakstan Kenya Kirgistan Kiribati Korea (North) Korea (South) Kuwait Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique (Fr.) Mauritania Mauritius Mexico Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands Neutral Zone New Caledonia (Fr.) New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Isl. Norway Oman Pakistan Palau Panama Papua New Paraguay Peru Philippines Pitcairn Poland Polynesia (Fr.) Portugal Puerto Rico (US) Qatar Reunion (Fr.) Romania Russian Federation Rwanda Saint Lucia Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa Soviet Union Spain Sri Lanka St. Helena St. Pierre & Miquelon St. Tome and Principe St.Kitts Nevis Anguilla St.Vincent & Grenadines Sudan Suriname Svalbard & Jan Mayen Is Swaziland Sweden Switzerland Syria Tadjikistan Taiwan Tanzania Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Minor outlying Isl. Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis & Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe -
COUNTRY

STATE OR PROVINCE
IF OUTSIDE US OR CANADA

PHONE - PLEASE INCLUDE COUNTRY CODE

FAX

EMAIL

ALTERNATE EMAIL

PLEASE SELECT DESIRED FEATURES

Complete Site Design
Web Site Makeover
Splash Page
Flash
Custom Graphics
Custom Logo
Database
Site Search
Forum
Chat
Knowledge Base
Help Desk
Member Login
Shopping Cart
Custom Scripts
SSL Certificate

CURRENT WEBSITE URL

1 to 5 5 to 10 10 to 20 20 to 50 more than 50
NUMBER OF PAGES

Immediately 1 Week 2 Weeks 1 Month 6 Weeks or more
PROJECT START DATE

$250 to $500 USD $500 to $1,000 USD $1,000 to $2,500 USD $2,500 to $5,000 USD $5,000 to $1,0000 USD over $10,000 USD
YOUR DEVELOPMENT BUDGET

PLEASE DESCRIBE IN AS MUCH DETAIL AS POSSIBLE
         EXACTLY WHAT YOU ARE WANTING DEVELOPED

The quote you receive will be an estimate to develop a web site based on what information you have submitted and will serve as a guideline to base your future development decision.

Please note that website development may include design, programming and images. It does not include website copy, or any content specific to your business.