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Website Development Request Form

Independence Computers designs Websites for both businesses
and individuals seeking presence on the world wide web. We also offer several maintenance plans for websites that require updates on a regular basis. If you would like more information about
website development, complete our online request form below,
and a sales representative will be in contact shortly.


First Name:

Last Name:

Email Address: (this is for us to contact you this 1 time only)

Phone Number: Areacode Number

Do you currently have a website: Yes No

If you answered yes, what is the current address:

Would you like to be contacted via Email or Telephone: Email Telephone