| Association Information |
| Do you currently belong to an association? |
Yes
No
|
|
Name of Association
|
Membership #
|
|
|
Which association are you interested in joining?
|
How did you hear about us?
|
|
| Contact Information |
First Name
|
Last Name
|
Business Name
|
|
E-Mail
|
Address (line 1)
|
Address (line 2)
|
City
|
State
|
Zip code
|
Main Phone
|
Mobile Phone
|
Best phone to call
|
Best day to call
|
Best time to call
|
|
| Current Website Information |
Do you currently have a website?
Yes
No
|
Current Domain (e.g. www.mysite.com)
|
Current Hosting Company
Don't Know |
| What I like or don't like about my current website: |
| Colors: Like Don't Like |
Comments
|
| General Layout: Like Don't Like |
Comments
|
| Navigation: Like Don't Like |
Comments
|
| Content: Like Don't Like |
Comments
|
| Domain Name: Like Don't Like |
Comments
|
Would you like us to find you a domain name?
Yes
No
|
We will check the availability of several domain names for you to choose from. Please provide us with some keywords you would like to see in your domain name. E.g., "Chicago, Newspaper, Agency"
|
| Additional Features |
| Please indicate below if you are interested in additional features: |
SEO Campaign:
This will optimize your page ranking on Google, Yahoo, and Bing. |
CRO Campaign:
This will improve conversion rates, ensuring the website is optimized for your target market. |
Live Chat:
A full-time customer service rep will monitor your website and provide feedback to your website visitors. |
Custom Animated Videos:
A streaming video designed for your business will be placed on your site to clarify your products and services. |
| Please enter any additional information or comments below. |
|
| I'm also interested in: |
Accident Insurance
Business Insurance
Critical Illness
Dental/Vision Insurance
Disability Income
|
Health Insurance
Life Insurance
Long-Term Care Insurance
Medicare for Seniors
None at this time
|
| Thank you for completing the form, so we can better assist you. We look forward to working with you! Please press submit now and we will contact you within 2-3 business days. |
|
