Date:
Saturday, September 04, 2010
Company Name:
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First Name:
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Last Name:
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Point of Contact eMail Address:
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Phone:
(
)
ext.
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Cell Phone:
(
)
ext.00000000000
(Optional)
Address:
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City:
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State:
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Alabama
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Zip:
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Project Requested:
Select One
Back end Design
Back end Re-Design
Domain Transfer
E-Commerce
Shopping Cart
SEO
Web Design
Web Re-Design
Web Hosting
Other
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Company Website URL:
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http://
https://
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Purpose of Website:
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Share Information
Sell Products
Both
Not Sure
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Existing Format:
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N/A
ASP
ASP.NET
C+
C++
C#
ColdFusion
DHTML
HTML
JHP
PHP
VB
VB.NET
XML
* Required
Existing DataBase Format:
Select
N/A
Access
MySQL
SQL
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How did you hear about us?:
Select
AOL Search
Constant Contact
ExcelChirpractic.com
Friend
Google Search
Leeham.net
MSN Search
MyMarineCorpsBall.com
Newsletter >
Repeat Customer >
Yahoo Search
Other
Other Search
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Additional Information: