Web Design Referral Program:

Contact Information
  Customer Name:
  Company Name:
  Email Address:
  What is the best time to reach you ?
  And at what number ?
  Alternate number ?
Web Hosting Experience
  Do you currently have a web site ? Yes No
  If so what is your URL ?
  Are you happy with your site ? Yes No
  What would you do different ?
  What will the nature of your web site be (ex: Business, non-profit, personal, etc.) ?
  When do you need the web site to be completed -- Timeframe (ASAP, 3 weeks, 3 months, etc.) ?
  Will you be supplying Logo and/or graphics ?
  *