1 2 3 WebHost.com - Web Design

In order to serve you better, please fill out the form below. We will use the information to plan your web pages, site design and layout. We will then contact you within 3 business days with a custom price quote. Or if you have a quick question you can use the short contact form.

Client/Organization Information:
Company Name:
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Country:
Telephone:
E-Mail Address:
Objective/Purpose/Mission of Web Site: State the purpose for having a World Wide Web site:

	To establish a presence on the Internet and the World Wide Web.
	To advertise product information and price lists to customers.
	To sell products directly taking credit card information over the Internet
	To have potential customers contact you by phone or mail.
	Other

Domain Name (www.yourbusiness.com): Goto Step 1 to find if your domain is taken.
Desired Domain Name: (Example: companyname.com)
Please enter your second choice: (Example: companyname.com)
Desired E-Mail address: (support@yourbusiness.com)
Please enter your desired E-Mail alias: (additional E-Mail address)

Index/Home Page:
Page Title (To appear at the top of the Web browser and will show on listing by web search engines)
Page Description (200 characters or less to be used by search engines)
Page Keywords which people might use to find your company product or service (separate words with commas)

Navigation and Layout Design:
Top of page Navigation Bar?	Yes No
Side of page Navigation Bar?	Yes No
Bottom of page Navigation Bar?	Yes No
Image Maps?	Yes No	Estimated #:
E-Mail response link(s)?	Yes No
Copyright at bottom of pages?	Yes No
Last modified date at bottom of pages?	Yes No
Estimated number of pages:

Web Page Content:
Graphic(s):	Yes No	Estimated #:
Standard company information:	Yes No
E-mail response link:	Yes No
Copyright/Disclaimer on each page:	Yes No
Navigation (by Image Map) on each page:	Yes No
May we include a link to "Designed by 123 WebHost"?	Yes No
Other:
Web Page Format Elements:
Desired Text Color:
Desired Typeface:
Size of normal text type: (relative to the user's settings in browser)
Desired Background Color or Texture: A white background with a band of color on the left margin offers the best readability and contrast.
Background Image
Graphics:
Company Logo?	Yes No
Photos?	Yes No	Estimated #
Other Graphic Images/Clipart?	Yes No	Estimated #
Need Scanning of Images?	Yes No	Estimated #
Need custom designed graphics?	Yes No	Estimated #
Multimedia:
Animated GIFs	Yes No	Estimated #
Sound (MIDI, WAV)	Yes No	Estimated #
Other
Forms for Customer Response:
Guestbook	Yes No
Customer Feedback/Comments	Yes No
On-line Orders	Yes No
Other (If you want to receive credit card information, you'll need an SSL-secure server or if you have an account with us you can use ours http://yourcompany.123webhost.com )
Custom Design Considerations: (Please list any other special needs) CGI, JAVA, etc.: (Please list any needs for custom programming)

Note: Web Site Hosting is not included.