Website Technical Intake Form

CONTACT INFORMATION
1. Contact Name:*
(Single Point of Contact)
2. Company Name:
3. Contact Phone:*
4. Contact Email:*
WEBSITE HOSTING INFORMATION
5. Website Hosting Company Name:
(if NicheLabs, leave blank)
6. Website Hosting Username:
(if NicheLabs, leave blank)
7. Website Hosting Password:
(if NicheLabs, leave blank)
DOMAIN INFORMATION
8. Domain Name:
9. Domain Registrar Company Name:
10. Domain Registrar Username:
11. Domain Registrar Password:
SEARCH ENGINE INFORMATION
12. Google Business Gmail Address:
(if you have one)
13. Google Business Gmail Password:
(if you have one)
14. Keywords:
(what keywords should be included on your new website)
ECOMMERCE INFORMATION
15. Payment Gateway Name:
(if selling online. If not, leave blank)
16. Ecommerce / Payment Gateway Username:
(if selling online. if not, leave blank)
17. Ecommerce / Payment Gateway Password:
(if selling online. if not, leave blank)
Email
This field is for validation purposes and should be left unchanged.

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CONTACT INFORMATION