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Simple php form for website with SMTP Authentication

I need a simple php form for my website with SMTP authentication.

The form needs to be put in the existing template of the website.

the form has four fields:

Voornaam (first name)

Achternaam, (second name)

Bedrijfsnaam (compagny name)

e-mail adres. (mail adres)

After the form is submitted its sends the contact details to a give mail adres and reguires smtp authentication.

The visitor gets a confrimation massage on the website and gets send back to the first page. and the given mail adres recieves the information.

I first like to see the lay-out of the form in an image. So i know how its going to look.

Im looking for someone who can do this task fast and not to expensive.

Thank you

Taidot: PHP, tietojärjestelmäarkkitehtuuri

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Tietoa työnantajasta:
( 7 arvostelua ) Bilthoven, Netherlands

Projektin tunnus: #4243860

Myönnetty käyttäjälle:

sourov06

I am the expert here to help you with your [login to view URL] check my PM.

$35 USD 2 päivässä
(10 Arvostelua)
4.5

8 freelanceria on tarjonnut keskimäärin %project_bid_stats_avg_sub_26% %project_currencyDetails_sign_sub_27% tähän työhön

kleelof

Hello, Please read the accompanying private message. take care, lee

$60 USD 4 päivässä
(106 arvostelua)
6.9
op2i

We can develop this mailing script for you, ready to start.

$180 USD 3 päivässä
(32 arvostelua)
6.2
webzin

Hi Have Gone through your requirement and understood, we are very sure that we can do your needs with your entire satisfaction. We have left a PMB for you plz feel free to have a look over there. Thnx Ram Webzin I Lisää

$200 USD 5 päivässä
(48 arvostelua)
6.0
phpplay

I am very much interested. Thanks

$75 USD 2 päivässä
(17 arvostelua)
5.5
maasoft

php expert is [login to view URL] 8+yrs of [login to view URL] to start Immediately.

$100 USD 2 päivässä
(46 arvostelua)
5.3
diamond1027

Hi, I can do it perfectly. I have rich exepriences on this fields. Best regards.

$150 USD 3 päivässä
(21 arvostelua)
4.5
codemaster7

Hello, I know exactly how to do this. More details on PMB. Regards, Andy.

$35 USD 1 päivässä
(7 arvostelua)
3.2
brlalithkumar

Sir, I am very interested in your project.

$30 USD 0 päivässä
(2 arvostelua)
2.2