WEB DESIGN ASSESSMENT FORM

Page 1 of 3

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.
Invalid Input

Your name & surname!

Invalid Input

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

Your address! is missing or has invalid characters

Postal code!

Your town!

Your Country!

Your e-mail address!

Invalid Input

Telephone number!

Cellphone!

Fax Number

Specialization Area/Products/Services?

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

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

Please give FULL details about your new website below.

Please specify your Web site Language option

Highest budget for this project!

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.

Invalid Input

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.

Please enter Extra Web services needed!

Please fill Extra Web services of your choice

Please write domain name to be registered

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

Please write project details, description etc

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

Write known project target audience!

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

Upload passport page1!

Duration of Site construction!

Upload EVIDENCE of your identity: Passports, National ID-Card etc

Invalid Input

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 name!

Bank account number!

Bank code/zip!

How did you know about us?

Invalid Input


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
Can´t see this clearly: Refresh code Please enter security code above!

Off Canvas Menu