Business Name Your Name Mailing Address City State - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Telephone Email Address Website Address Do you have a website? --- Yes No Halfway Do current customers ask you if you have a website? --- Yes No Do any new customers say they found you online? --- Yes No Sometimes Do you use social media? --- Yes No Constantly Don't like it Internet Experience --- Minimal Average Above Average What do people search for when they look for you? Delete this and add your own text. What words or groups of words would people use to search for your product or service online? Other comments or questions When would you consider website design or upgrade? --- Yesterday Soon This month Next month In three months Unsure Other Would you like information on Online Marketing Services? --- Yes No Would you like to learn website design inhouse? --- Yes No Maybe