Information Request Form

Website Details

Please Fill out this form in regards to your website
- Name*
  
  First NameLast Name
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.
- Billing Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Business Name*
  example: Web Graphx Solutions
- Business Email*
  example@example.com
- Business Phone Number*
- Business Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Business Hours *
  Enter the Hours of Operation if you are open 24hrs enter "24hrs"
- Online Sales*
- Suggest a Domain Name*
  Enter the domain name that you would like to use.
- Page Count
  How many pages do you see your website having?
- Primary Color On Website*
- What is the service area that you want to target? Please be as specific as possible.
- Service Area*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Radius of Service Area*
  Miles
- Instagram
- Google My Business
- Facebook
- Twitter
- Upload Logo Here
  
  Cancelof
- Privacy Policy
  
  You agree that all the information you have entered above is correct and you accept the responsibility for errors on the completed website under the assumption you have given us the incorrect information. We do not sell or give your information to anyone for any purpose. It will only be used during the design and construction of the website. We will hold information for up to a year after the end of the contract terms have terminated in the event that you have issues with the website and would like us to revisit and assess the problem.
  
  Terms and Conditions
  
  Upon signing this document you have given us the right to use the above information to construct a website. We will keep in close contact with you and make the process as fluid as possible under the agreement that you will provide additional information if we deem it necessary. We will attempt to contact you for any major decisions that need to be made in regards to your website. In the event that you can not be reached we may stop the project and charge you for an unfinished project. We will make every attempt to work with you on your schedule and get the project done by the delivery date. By signing this document you agree to the above Privacy, Terms and Conditions.
- Please verify that you are human*
- Please Sign Here*
  
  All information will not be sold, shared, distributed in anyway.
- Should be Empty:

Website Details