85618 Contact Form

ATTENTION: IF YOU HAVE A DEMO OF THE REQUESTED ITEM BELOW PLEASE SEND PM. DEMO MUST BE PROVIDED AND TESTED ON MY SERVER BEFORE PAYMENT IS MADE ========== I need a one page contact form which has detailed questions with a few radio buttons. The script must be secure and require visitor to input a number based on an image generated at the bottom of the script before the submit button can work. Script must call a header and [login to view URL] file to enable design work to be added with ease. The following is the outline for the one page [login to view URL] form: ================================ Tell us about yourself: (Please complete all applicable fields) - First Name: (text input) - Last Name: (text input) - Daytime Phone #: (text input) - Evening Phone #: (text input) - Email: (text input) - Confirm E-mail Address: (text input) - Street Address 1:(text input) - City:(text input) - State:(text input) - Zip Code:(text input) - Are you looking to buy a home or refinance an existing home? Buy (radio button to choose) Refinance (radio button to choose) - If refinancing, how much do you currently owe on the property? (text input) - What is your home's estimated value?(text input) - What is your current interest rate?(text input) - How much is your approximate gross annual income(all borrowers)?(text input) - Are you a first time homebuyer? Yes(radio button to choose) No(radio button to choose) - Any additional information you would like to provide? (text input) ============================== This script must support both SMTP and sendmail functions to insure it works on any server setup (server being used will always be linux based). Once the main page is filled out by the visitor and the secure code is typed in, visitor has clicked submit then the visitor should be directed to a thank you page. Security is a must to avoid spammers exploiting the script and using it to spam the owner and others. Clean layout is also required.