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First Name

Last Name

Email

Phone Number

Address

City & State

Zip

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Current Website / Social Media Information

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Do you currently have a website domain?

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If yes, what is it?

Do you currently have web hosting?

Yes

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If yes, who is it?

Do you have a Logo?

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On your Current website, what aspects work well & why?

On your Current website, what is NOT working well & why?

Provide any Social Media links you have that you would to include on your new website:

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New Website Build

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Choice of Website Enhancements

AQ Website Quoter

Facebook Feed

QR code

Testimonials

Google Reviews

Website Target Audience: Check all that apply

Life

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Choose your Theme Finance - Default Home Page Finance - Agency Home Page Finance - Corporate Home Page Ensure Eden Verona Elder Care Finatic Regency Spectrum Landing Page *Life only market

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