Name:

Phone number:

E-mail address:

Mailing address:

Type of business:

Company:

1. How would you like us to contact you regarding the quote?.

Email Telephone Regular mail

2. Please list 2 or 3 websites that you feel convey an image similar to your business, or you would consider to be attractive, effective or functional.

a):

b):

c):

3. Select all items that you intend to use the website for:

4. If you have a budget in mind, please indicate the level.

$1,000- $2,500 $2,500 - $5,000 $5,000 +

5. How did you hear about Delta Decisions Inc.?

6. Please describe briefly what you are trying to accomplish with the web site. Or simply describe the features you would like us to quote on.

7. Please enter a deadline date if applicable: