Name:

E-mail address:

Phone number:

Best time to call:

Company name:

What line of business are you in?

Target market/industry:

Do you currently have a website?:

List the websites of your three main competitors:http:// http:// http://

Is there anything else you would like to tell us about your business?:

What type of work are you looking for?: -Please select one- New web site design Re-design and existing site Site maintenance

How many pages are you anticipating?: -Please select one- 1-5 6-10 11-15 more than 16

How much of an investment are you anticipating?: -Please select one- $1,000 - $2,000 $2,000 - $3,000 more than $3,000

When do you need the project to be completed?: -Please select one- within one month one to three months three to six months six months or more

Do you wish to sell products or services on your site?: Yes No

If 'Yes', do you already have the ability to accept credit cards?: Yes No

Do you need to be able to make changes to the site yourself?: Yes No

List any websites that appeal to you:

How did you hear about JMF Web Design?: -Please select one- Client referred Web search Saw another JMF Web Design Site Other

If 'Other', please specify:

If 'Referred', please tell us who it was: