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*First Name:
Last Name:
*Organization (Co. Name):
Address:
City:
State/Province:
Zip / postal code:
Country:
Telephone number:
Fax number:
*E-mail:
*What type of services do you need?	Design a new web site Web site development E-Commerce web site Intranet design & development Site maintenance Web site re-design & optimization Other (please specify):
*Please describe your business including products sold, industry, etc.:
Number of employees:
Web site:
*Do you need photos taken, graphics created, images scanned:
*Please describe the purpose of the web site and provide any other information that you feel will be helpful
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