D W D Customer Information Form

Contact Information

Customer Name:
Address Line 1:
Address Line 2 :
City:
State/Province:
Zip/Postal Code:
Daytime Phone:
Fax:
Email:

Order Information

Please give the name and explain the purpose and audience of your web site here:
Below, please make the appropriate choice about your logo:
I already have a logo I want to use.
I would like you to develop a logo especially for my website.
Please choose the number of pages you would like on your web site. Please select one only:
Please make me a 2 page site for $200.
Please make me a 3 page site for $300.
Please make me a 4 page site for $400.
Please make me a 5 page site for $500.
Please make me a site at $100 a page. I'll specify the number of pages below:
Number of Pages:
Your web site will be built with a Home Page and a group of other pages. You have the option to use the Ctrl key to make multiple selections.
Which pages would you like to include?

Please list and explain any other pages you would like to include here:
If you would like to check your information after you order then enter a user name and password below:
User Name:
Password:
Verify Password:

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Last updated 7-23-01 by Cathy Buckingham