Namibia Web Site Design & Hosting
Services Request Form

Completion of this form provides us with the information we need to assit you with specific web site services we offer. Once received we will revert to you without delay. All information submitted is treated fully confidential.

Part 1
Email address: (must be filled in)

First & last name:

Company

Address: Suite/Apt:

City: State/Province:

Country: Postal Code:

Phone (incl. area code):

Fax (incl. area code):

Part 2
I am interested in Web Site Design & Hosting:

Do you have presently a web site and if so, please fill in the address:

We will visit your site to get a basic understanding of your product and contact you soonest.

Part 3

I am interested in Web Site Registration only:

My web site address is:

Part 4

I am interested in placing a Classified Ad:

Headline of the Ad:

Subject Matter of the Ad:

Your asking price in US$:

Text of the ad (no more than 255 characters):

Please repeat your e-mail address:

Please repeat your web site address:

Your comments & suggestion are important to us:

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