The Painted Page

Client Information Request Form

Name:
Address:
City:              State:      Postal Code:
Country:       E-mail Address:

Phone:

Please send me an estimate of cost and time regarding the following:

Lay out and Design
Brochure	Flyer	Business Card	Newsletter	Letter head
How many Graphics?	How many Graphics?	How many Graphics?	How many Graphics?	How many Graphics?
Client will provide: Text Graphics	Client will provide:	Client will provide: Text Graphics	Client will provide:	Client will provide: Text Graphics
	Text Graphics		Text Graphics

Web Lay out and Design
Flash Intro Page	HTML Intro page	Additional Pages	Monthly Maintenance	Web Hosting
How many Graphics?	How many Graphics?	How many Graphics?	How many Graphics?	I need web hosting
Client will provide: Text Graphics	Client will provide: Text Graphics	Client will provide: Text Graphics	Client will provide: Text Graphics	I will provide my own:

Original Art work Technical Writing

Please add any additional explanations:

Please contact me: check all that apply
E-mail Phone Mail I will contact you