Service Request "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Person Submitting This Form*Date of Sale* MM slash DD slash YYYY Systems Admin Needed* Project A Scarab Media Client InformationCompany/Organization Name*Primary Contact Name (First and Last)*Primary Contact Email* Primary Contact Phone*Billing Contact Name (First and Last)If different than primaryBilling Contact EmailIf different than primaryBilling Contact PhoneIf different than primaryAddress (Street, City, State, Zip)*Service InformationType of Service* WordPress (Beaver Builder) WordPress (Basic) WooCommerce SIB Static Site Custom VPS Hosting Shared Hosting Other (Specify) Other ServiceEmail Services* Yes No Unknown FTP Services* Yes No Unknown Domain InformationWeb Address (Primary)Domain Services (Primary) Existing Domain - No services needed Existing Domain - Transfer to Project A managed New Domain - Project A to register New Domain - Client will register DNS Transfer Redirect SSL - Let's Encrypt SSL - Pinwheel SSL - Other Number of Years to Register Domain (Primary)Number of Years to Register SSL (Primary)Web Address (Secondary)Domain Services (Secondary) Existing Domain - No services needed Existing Domain - Transfer to Project A managed New Domain - Project A to register New Domain - Client will register DNS Transfer Redirect SSL - Let's Encrypt SSL - Pinwheel SSL - Other Number of Years to Register Domain (Secondary)Number of Years to Register SSL (Secondary)Web Address (3)Domain Services (3) Existing Domain - No services needed Existing Domain - Transfer to Project A managed New Domain - Project A to register New Domain - Client will register DNS Transfer Redirect SSL - Let's Encrypt SSL - Pinwheel SSL - Other Number of Years to Register Domain (3)Number of Years to Register SSL (3)Fees and ChargesInitial Setup Fee(s)Total of all Setup FeesRecurring/Ongoing Fee(s)e.g. fees for Hosting, Domains, SSL, Plugins, Care Package, Email, etc. List each per month, quarter, or year.Begin Billing Date* MM slash DD slash YYYY Billing Method* Credit Card Check Initial Billing Setup* Auto-pay (We have card on file) Auto-pay (Accounting needs to collect card info from customer) Online/Email Bill (Customer initiates payment online) Unknown/NA Other Billing NotesDeposit amount to bill, etc.Comments/Details/Instructions
