EZNET Total Access 848 4th Ave. 3rd Floor Huntington, WV 25701 Email: info@ezwv.com Fax: (304) 525-3772 Date:___________________ NAME:_______________________________________________________________________ COMPANY NAME:_______________________________________________________________ ADDRESS:____________________________________________________________________ CITY:_______________________________________________________________________ ZIP CODE:______________________________ STATE:_____________________________ PHONE:_________________________________ EMAIL:_____________________________ FAX:___________________________________ What is the best way to contact you? ___ Phone ___Email What is the nature of your business? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What is your current web site address? ____________________________________________________________________________ Do you have a host for your site? If so, whom? ____________________________________________________________________________ Why do you want a web site and what would you like it to do for you? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Do you have a budget for this site/project? ___ yes ___no Do you want to sell something on this site? If so, what? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What is the nature of your business? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Do you have a merchant account for this site? ___ yes ___no How do you plan to advertise, market, leverage this site? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ If this is a new site, is it planned out and flowcharted? ___ yes ___no Do you have a logo? ___ yes ___no If yes, do you have it in a usable PC format? ___ yes ___no What is your time-frame/deadline for this project? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Please list any additional information that you feel may be useful in assessing your needs, like URL's that you like or of your competition, concerns you have about this project. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________