Your Name___________
Company ____________
Type of Business____
Mailing Address_____
City________________
State_______________ ZIP
Telephone number____
Email address_______

Please include a list of objectives you would like your Web site to accomplish:


I would like the following:

a no obligation phone call about EZ New Media Internet Services
an information packet by mail
additional information via email (please be very specific)
none of the above

I am contacting you because:

We need a new Web Site for our business NOW!
We will need a new Web Site within the next three months.
We want information about EZ New Media to keep on file.
none of the above

I am also interested in your Web Site Maintenance Plans:

Yes: I am interested in learning more about EZ New Media Web Site Maintenance
No: I am not interested at this time

Please include any comments or specific questions you would like answered:


*

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