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Title:
Name : 
Address : 
Address 2 : 
City or Town : 
State : 
Zip/Postal Code : 
Day Phone: 
Eve. Phone:
Email: 
Do you have a domain :
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If yes, what is it :
Do you have a domain but no web site?
Yes No Under Construction
Do you have a web site,
but not your own domain?
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If yes, what is the URL: http://
What type of service are you interested in:
Check all that apply
Design Hosting Design & Hosting
Marketing E-Commerce
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What will be (is) the purpose of your web site?: Check all that apply
Establish an e-presence
Provide information
Sell products online (e-commerce)
Provide customer service
Other (please specify)
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