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WEB DESIGN ASSESSMENT FORM

Important Instructions:
To register for the EuroAfrica Media Network Web Design (Ezehweb) please fill the form below.Please follow all the instructions carefully. Note to answer all questions appropriately, the better your answers, the better we will understand your wishes. Please Note: All fields marked with * must be filled out.
Title
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Name and Surname
Your name & surname!

Firm/Organisation
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...If an organisation please write here complete name of org.+ name/(s)of the responsible persons in charge.

Address(*)
Your address! is missing or has invalid characters

Postal Code (*)
Postal code!

Town(*)
Your town!

Country(*)
Your Country!

e-mail address(*)
Your e-mail address!

Web Site
Invalid Input

Telephone Number(*)
Telephone number!

Cell phone
Cellphone!

Fax Number
Fax Number

Specialization
Specialization Area/Products/Services?

Present SiteURL ( http://www.)
Present website! URL ( http://www....)?

Present website! URL ( http://www.)

Please give FULL details about your new website below.

Website Language(*)

Please specify your Web site Language option

Your highest budget(*)
Highest budget for this project!

Your Lowest budget
Your Lowest budget

Extra Web Components Desired Services for your new Website/Web packet information: NOTE: This is a list of the most common web site services. If your needs are not listed here please specify in the Comments section below. If you are not certain, Please choose all that may apply.

Extra Web Components

Please enter Extra Web Components!

Please fill Extra Web components of your choice:

Important Aspects For Cost Calculation Extra Web Services which might be needed or not needed for your new Website: NOTE: Please indicate here where you need help or not so we can have an idea of the volume of work required in your new website.

Needed Web Services(*)

Please enter Extra Web services needed!

Please fill Extra Web services of your choice

Domain Name for Registration(*)
Please write domain name to be registered

Write below in box Domain Name(s) to be registered

Project Details (*)
Please write project details, description etc

Please describe shortly and very precisely your ideas for the new web site.

Your Target Audience(*)
Write known project target audience!

Logistics: To facilitate timely/correct preparation, we need details.

Upload Banner, Logo etc
Upload passport page1!

Duration for Project(*)
Duration of Site construction!

IDENTIFICATION-DOCUMENT-PASSPORT-ETC-UPLOAD(*)
Upload EVIDENCE of your identity: Passports, National ID-Card etc

Other Uploads

Documents Uploads
Upload passport page3!

Please write below the details of your Bank Account - This is necessary for the Registration of your Website at the Hosting Company and is also very important for the processing of  this application.

Bank account holder(*)
Bank account holder!

Bank Name(*)
Bank name!

Bank account number(*)
Bank account number!

Bank Code/Zip(*)
Bank code/zip!

How did you know about us?(*)
How did you know about us?

Other comments
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Today´s Date

Today´s date!

Now read carefully through your filled form items to ensure every data is correct, check also in the upload fields to ensure you have photos, documents, banner etc included, thereafter please refresh and insert code below. By clicking on submit button below you accept the EAMN Terms and submit that you are18 or above and all information entered on this form is true to the best of your knowledge

Security Code(*)
Security Code
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