Customer Information:

  Business Name             Proprietor 

  Street Address     

  City                  

  State                     Zip Code               



  Phone Number              Fax Number 

  Hours of operation 

  Years in business      Email Address 

 
Services Offered/Specials 

 


What kind of payment do you accept?

Visa Mastercard American Express Discover

Cash Check      Money Order      Travelers Checks 

Guarantees You Offer 

 





Web Page Information: 


What name do you want in your title/banner line? 

What domain name would you like to use?  ie: www.hoperothrock.com



 Does this domain name already exist? 
Yes No

Do you have a specific color(s) you would like used on your webpage?

Yes  If Yes please enter Color(s): 

No



Do you have a LOGO you would like to appear on your webpage?

Yes No

Do you have a Picture(s) you would like to appear on your webpage?

Yes No

Do you want to have directions to your establishment on this page?

Yes No

Are there employment opportunities you would like to list?

Yes No

Please tell us any other info you like to see on this webpage: