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Customer Information

*Your Name:

*Company Name:

*Please specify your industry:


*Email Address:

*Phone Number:

*Best day/time to contact you:

*How Did You Find Us?

Project Details

What kind of website are you looking to have built?
 Informational E-Commerce Not Sure

Please Estimate Your Budget:

Existing website URL (if any)

Have you registered a domain name?
 Yes No

If yes, please indicate your domain name

Do you require the design of a logo?
 Yes No

Do you require email accounts?
 Yes No

*What is your time frame for project completion?

*Brief Project Description:

Reference Websites (if any):

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Mid America Web Solutions
4401 North Belt West
Belleville, Illinois 62226
Click Here for Map & Directions

Phone: (618) 355-5000
Fax: (618) 233-7072


Monday – Friday
9:00 AM – 5:00 PM