First name Required

 Last name Required

    E-mail Required



           Title 

         Company 

  Street address 

 Address (cont.) 

            City 

  State/Province 

 Zip/Postal code 

         Country 

      Work Phone 

     Pager Number

How Did You Hear About Us:	Select From List AltaVista BigBook Excite Four11 Infoseek Lycos OpenText WebCrawler Yahoo Other Search Engine BCD ONLINE Referral HyperLink Trade Show Other
Are You a New or Existing Business?	New     Existing
Business Type:	Select From List Corporation Partnership LLC Sole Proprietor Other
Describe Products Sold:

I would like a web site design for ;
Myself
My Company (Please continue with the next question.)
My Home-Based Business (Please continue with the next question.)

What is the primary business of your organization at your location?
accounting/financial/banking advertising/public relations aerospace agriculture automotive aviation chemical church/religous communications computer construction/building consulting/planning electronics entertainment food/beverage government agency graphics health care/medical/hospital higher education hotel insurance internet access provider janatorial/maintenance K-12 education legal manufacturing other pharmaceuticals printing/publishing real estate research retailer telecommunications transportation utility wholesaler

How many employees does your company have in total, including all locations?
1-50 51-150 151-1000 1001-5000 5001+ n/a

What is your primary job function?
Owner President IS Management Creative/Content Management Executive Management Sales/Marketing Management Operations Manager Finance Manager Engineer Clerical Teacher/Professor Student Other

Which statement best describes your role in the purchasing of web page development?
I decide all marketing.
I set company standards for marketing.
I evaluate and recommend advertising and marketing.
I have some influence in the advertising and marketing .
I control all advertising and marketing.

Does your company have a Internet access?
Yes No Don't Know
If yes:

• What is your Internet access company's name?
• Does your company want is own domain name?
  Yes No
• If no what name would you chose?

Does your company have an E-MAIL address?
Yes No Don't Know

If yes what is your E-MAIL address?

E-mail

Will you or your company be making a purchase or evaluation decision on an Internet web page design firm in the near future?
Yes No Don't Know
If so, how soon will that decision be made?
1-3 months 3-6 months 6-12 months Don't know

Comments:

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