Imbris, Inc. Web Hosting and Co-Location Request Form

610 W Hubbard, Suite 125
Coeur d'Alene, ID 83814
Customer Support

Web Hosting / Co-Location Proposal Request

Thank you for your interest in IMBRIS Web Hosting and Co-Location services. Please fill in the form below with your requirements. Should you be unsure of any information or selection, simply enter your best estimate or leave the field blank. After you click "Submit Request", an IMBRIS representative will review your information and contact you to begin the process for hosting your site or providing a quotation (so please be sure to enter your name and phone number correctly).
Items marked with an * are required in order to submit your proposal request.


Name:*
Title:
Company Agency:
Address 1:
Address 2:
City:
State/Province:
Zip/Postal Code:
Are you in the United States?: *	Yes No
Telephone:*
Fax Number:
Domain Name: if applicable
E-mail Address:*

Choose the Domain Hosting Package you prefer, or answer the questions below for a custom package.
UNIX Copper UNIX Silver UNIX Gold UNIX Platinum Win2003 Emerald Win2003 Ruby Win2003 Diamond

Which platform would you like your server to operate? UNIX Windows 2003
Would you like your site on a Shared or Dedicated Server (co-located)? Shared Dedicated
Do you wish your site to have mirrored servers for fault tolerance? No Yes
Estimated size of content?
Applications which you intend to integrate into your web site?
Animated Graphics Audio FTP Video Ad Management
Interactive Database Queries Commerce/Secure Transactions
Estimated hits per day to your web site?
Average page size?
Internet connection to support content updates or Remote Console Access required?
None Required Dial up DSL Frame Relay T1
Do you currently have an active web site? No Yes
If yes, what is the URL:
If yes, how are you currently hosting your web site?
Internally Outsourcing to an ISP (which one):
Would you like a referral for a web content developer? No Yes
Estimated time frame for service startup?

How did you hear about IMBRIS?

Direct Mail
Web/Internet Search, From:
Print advertisement, From:
Trade Show, City/Date:
Referral:
Other (Please explain):

Are you currently an IMBRIS customer? No Yes
Please provide any additional comments: