Free Web Design - Order Form

Please complete the form below so we may provide you with a free website design within 48-72 hours.

  * Fields are mandatory
  * Client Details :
  Client Name:
  Email Address:
  Cellphone No:
  Alternate Contact No:
  Domain Required eg. :
  Email Required eg. :
  * Business Details :
  Name of Business :
  Types of Products/Services you sell :
  Address of Business:
  Business Telephone No:
  Contact Person in Business:
  Colours Required in Website(2only) :
  Home Page Text:
  About Us Text:
  Provide Details of Products/Services you want listed on the website (more can be added after activation) eg. Plumbing Service - we provide affordable plumbing services all over Cape Town :
  Product 1:
  Product 2:
  Product 3:
  Product 4:
  Product 5:
  * Debit Order Details :
  Account Holders Name:
  Account No:
  Account Type eg.Cheque:
  Branch Code:
  * Please select your debit order date :

Please email all images, logos and additional information that you would like to be utilised in the design of your website to  

   By clicking the submit button below,the client agrees to the debiting of the account provided above and to the once off domain registration of R165.00.

The client confirms that they agree to their account being debited on a monthly basis for the monthly ecommerce hosting fee of R165.00 (excluding Vat).