Asterisks (*) denote required fields.

General Information

*Business or Organization Name *Federal ID Number

Contact Information (This information is for our records and will not be published on the Website.)

*Last Name *First Name M.I. *E-mail *Phone (i.e 000-000-0000) Fax (i.e 000-000-0000)

Address Information

Organization Mailing Address *Address1 Address2 *City *State *Zip Organization Physical Address *Address1 Address2 *City *State *Zip Same as mailing address.

Security Information

*Please create a 4 digit PIN. *Choose a security question What is your favorite word? What is your favorite holiday? What was the color of your first car? What is your favorite dessert? What country would you like to visit? *Answer Please list the name of a secondary account holder.

Website Information

*1. Do you have a current Website? Yes No *1a. Current Website Address *1b. Who currently hosts your Website? *1c. With whom did you register your domain? 1a. What domain would you like for us to register? (Please list your preference plus two alternatives in the event your first choice is not availble.) *Primary *Alternative *Alternative *2. Can you provide a current logo in digital format? Yes No *3. Can you provide digital photos relating to your organization? Yes No *4. What colors would you like to use for your site? *5. Do you have someone in your organization who will be able to maintain your site with training from our company staff? Yes No *5a. Please list name.

Features

The following features can be added to your Website. Please check sections for which you can provide information and would like to have included on your site. Frequently Asked Questions Contact Us Form History of Company Calendar of Events Map of our Location Links Photos of our Store and Products News (i.e., online Press Releases) Staff Directory E-mail Newsletter Signup Form Photo Gallery Additional Features (Please list any other feature that you would like to see on your Website.)

Non-Profit Information

Does your business or organization need financial assistance in the design, hosting, or maintenance of a Website? Yes No

*1. Are you a 501-C3 non-profit organization? Yes No 1a. (Yes) Please send a copy of your non-profit determination letter. *1a. (No) Please list your type of non-profit organization. *2. Do you have matching money for your Website? Yes No *2a. (Yes) Percentage of match? *3. How is your organization funded? *4. How much of the Website cost is your organization able to pay? 100% 75% 50% Other None *5. What is your mission?

Executive Officers and Board Members

Check if Photo is Available Name Title