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Please complete, to the best of your knowledge, all of the information on the form below in order for us to understand your custom Web site development needs.

The more information you complete, the more accurate our quote will be. If you don't want a custom web site developed, visit our Site Show Gallery to view pre-designed Instant Web Site templates that can be modified through our web Site Manager and purchased at significant savings in comparison to a custom site.

Free Custom Quotes are guaranteed for 30 days.

We only develop custom web sites for individuals, businesses or organizations located in the United States and Canada.


Contact Information
First Name:
Last Name:
Company or Organization Name:
Street Address Line 1:
Street Address Line 2:
City:
State:
Zip Code:
Office Phone:	-
Office Fax:	-
Other Phone:	-
E-mail Address:
How can we contact you if we have questions regarding your request?
How would you like to receive your quote?

About your business/organization
Type of Business:
What is your budget for this project?
Please describe your business including products sold, industry, etc.:

Requirements of Proposed Site
1. Is this a re-design of an existing site?	New Re-Design
2. If a RE-DESIGN, what is the current URL?
3. Do you have the copy written for the site?	Yes No
4. If YES, is it in a digital format?	Yes No
5. If NO, do you want us to write it?	Yes No
6. Do you have photos for the site?	Yes No
7. If YES, are they in a digital format?	Yes No
8. How many graphic images/photographs?
9. Do you have a logo/graphics a for your business?	Yes No
10. If YES, are they in a digital format?	Yes No
11. Approximately how many pages?
12. Will you plan to sell anything on your site? (e-commerce)	Yes No
13. Would you like to accept credit cards on your site? (Note: e-Commerce Merchant site prices begin at approximately $3000.00 and monthly hosting costs are much higher than non-Merchant sites)	Yes No
14. Do you currently have a Merchant Account?	Yes No
Will you plan to create a database for your site?	Yes No
Do you have a Domain Name registered? (e.g. www.mysite.com)	Yes No
If you answered "Yes", please enter your Domain Name?
If you do not have a Domain Name registered would you like us to register one for you? (You will be billed a $14.95 yearly fee for a .com, .org, or .net address. Register now through Domainlot to reserve your address. You can return this page after you are done. Other address extensions may be available at higher costs.)	Yes No
Please write down the address of three web site examples you LIKE:
Which one is important for you in a web site: Colors Style Concept Simplicity Advertisment It does not matter Other
If your answer is other what is important for you?:
Additional information, requests, ideas, or examples of Web sites you like:
Are you currently an ActiveCom customer?	Yes No

We respect your privacy. The information collected will only be used to assess your Web site development needs.
We do not share this information with any third parties.