Full Name:

Address:

City:

State: Zip:

Phone: Fax:

Email address:

Verify Email address:

What package would you like to purchase: #1 #2 #3

Do you have an existing site: Yes No

If "yes" please provide your URL (site address):

If "no" would you like to have your own domain name:

(www.yourbusinessname.com)

**Registration for your domain name is $15 for a year. This fee is not included in a package.

**This will be invoiced seperately by your domain provider

Yes No

Please describe your business in detail:

Include business name

Will you be providing your own graphics: Yes No

If "no" describe what kind of graphics you would like created:

Any further details:

*Please note that PG Design requires 50% down before any services are rendered. This fee will be applied to your full package price. If you decide that PG Design's services are not right for you or your business, then 50% of the intitial fee will be reimbursed. Thank you!