Vivax Web Site Order Form

Use Our On-line Forms:

	Customer Service
	Technical Support
	Information Request
	Order a Web Package
	Have a Vivax Representative Call
	Comments or Suggestions
	Message for the Web Master
	Job Opportunities

Use this form to order your Web Development Services or, if you prefer, e-mail Sales Support. This form may be used for ordering your QuickStart Package or to provide us with basic information about your business so we can be prepared before we contact you.

Client Company Information

Company name:
Company address:
Preferred domain name:		*This is a registered* Internet Address (Please list your choices in order of preference. We will check and let you know about availibility.)**
Your e-mail address:
	(In case we cannot reach you by phone.)
Contact Information

Contact name:
Your phone number:		Please call me
Your Fax number:		(Optional, listed on your site)
Where are you located:
Best time to call:
Web Site Requirement

Objective of Site:		Enhance the image of the firm Reach out to new clients Improve relationship with existing clients Improve productivity Increase profitability Sell products (E-Commerce) Provide support services Other (See Comments Below)
Other Information:		You have a business card/Letterhead You have a Logo You have additional graphics/photos You require Vivax produced graphics You require Video for your site You require Audio for your site Special requirement (See Comments Below)
Service or Product Description:
Your Current Client Profile:
Additional Comments:
Web Package:		QuickStart Web Package Custom Designed Web Site

Customer Service
WebMaster

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