CRITIQUE REQUEST FORM

Please read the critique information before completing this form.

At present we cannot take online payments (coming very soon). On completion of this form our office will call you for credit card information.

Last Name:

First Name:

E-mail:

Phone Number:

Address 1

Address 2

Address 3

City

Zip/Postal Code

State / Province / County

Country

Website URL

http://

Website size in pages:

1-15 16-30 over 30

Website Type:
(Business, information, product sales, chat, games, etc)

Website Description:
What your website is about and what message it is trying to convey.

Access Information:

Please indicate if your site requires passwords or login data. Please be ready to supply this information at time of payment.