Request Form-Chuck Gant's Web Design, Maintenance, Hosting. Complete website solution. Master CIW designer.

Here at chuckgant.com we strive to create a site that's consistent with the look and fill of your organization. We work with you to create a site that fits your needs and the needs of your audience. We help you create a site that is easy to use and easy on the eyes. What ever your needs we can help.

Your site will be created by a "Master CIW Designer" with experience in meeting customers needs. Once your site is finished, that same designer can manage your site to insure functionality and consistency.

Web Design Request Form

Name	*
Address
City
State
ZIP
Email	*
Telephone
Name of sales rep. or referrer (If applicable)	Name, or Company
I am interested in	*
Project Time frame
Project Budget	to
What is the purpose of this web site?	Personal Business Other Explain:
Do you currently have a web site?	Web Site: Yes No If so, what is your current URL:
List some site that are similar in design to what your looking for.	http://www.
Estimate how many pages your site will contain.
Please list the menu items for your web site.	Home Page,
Tell us about your project (Please be detailed).
Do you want to accept payments for products on your web site?	Payments: Yes No If so, who will you be accepting payments with? PayPal Merchant Account Other Undecided
Do you need a domain name?	Yes No
Do you need web hosting?	Hosting: Yes No If so with who? ChuckGant.com Other
Do you need site maintenance?	Yes No