Quote Form

Check off type of services required:

Hosting
Domain name registration
POP Email Accounts
Email list and management
Graphic Design
Custom Web Design
Other - Please specify:


Check off which features you would like:

Media Database
Drug War Clock
Content Management System
Bulletin Board/Forum
MySQL database
Video/Audio
Newsfeed:

Newsfeed type:
Simple Bulleted List
Detailed Bulleted List
Drop Down Menu
Table
Custom

Additional Features:


Do you have a registered domain name? Yes No
If so, what is it?

If not, please list choices:
1st choice
2nd choice

What level of support do you need? :
Total Support (want DPC to do everything)
Partial Support (know how to use the support page)
Moral Support (just need service/minimal tech support)

Will you be applying for a grant with us for this project? Yes No

If yes, please fill out the following information:
How long has your organization existed?

How many members does your organization have?

Have you applied for a grant with us before? Yes No
If yes, please state when

Was your grant application ever turned down? Yes No

Do you receive any type of funding? Yes No
If yes, please list source
If yes, how much annually?

What is your budget?
less than $500
$500-$1000
$1,000-$2,500
$2,500 or greater
Not sure

What percentage of website cost do you require funding for?
100 %
75 %
50 %
25 %
Not sure

I agree to support DrugSense/MAP/DPC by becoming a member

Name of Organization
Contact person
Email address
Telephone Number

Please describe your organization, your goals and accomplishments:

Additional comments or information:

How did you hear about Drug Policy Central?


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