New Client Form - Justin Long LLC

Date
Name of authorized representative *
Legal name of business/entity *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *
Email for communication with Justin Long LLC *

Business/entity name to be used on website *
Street address to be used on website. Enter N/A if none. *
Phone to be listed on website. Enter N/A if none *
Do you already own a domain name that you want to use? If so, please list.
If you have your own domain name, please provide login link, username and password
If no, specific domain name desired (if unavailable, we will discuss your options)
Your website comes with free email. Would you like to add an email address?
YesNoLater
If yes, please list all desired email addresses. Example: yourname@yourdomain.com Your domain name will be the part after the @. You can choose anything you like to go before the @.
Email(s) to be listed on website
Please list any special information here.
Agreement: This agreement is between the above-listed entity and Justin Long LLC for the construction and maintenance of my website. By electronically signing and submitting this form, I agree to pay the website construction fee listed below, and I also agree to the monthly maintenance fee of $100. I understand that failure to pay my monthly bill could result in my website being taken offline. I agree that I am ultimately responsible for the content of my website.
Agreed website construction fee *
Signature of authorized representative *Type your full name as your electronic signature