Your Name (required)

Your Email (required)

Your Business Name (required)

Please describe your business, products or services (required)

Business Address (required):

Business Phone (required):

Does a live person answer this phone? Yes No 

FAX number to include in ads:

Will you provide logos for your ads? Yes No 

Will you provide digital images for your ads? Yes No 

Will you use coupons or discounts in your advertising? Yes No 

Can you provide customer testimonials? Yes No 

Who is your target audience? Primary, secondary…

What words or phrases would your target audience use to find you? (required)

Who are your main competitors? (required)

What is your most profitable product or service?

Do you have a web site?  Yes No

Your web address:

What is your average customer ticket amount?

How many customers do you average per month?

What forms of advertising do you currently use?

What do feel is working best for you?

Can you provide copies/samples of current advertising?  Yes No

What is your most important message?

How will you measure success of an internet campaign?

Do you have comments or special instructions?