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PHP Form for my website--lowest bidder gets job

I need a PHP Form for my website. The form can send to my email address. And please, do NOT put your email address in the form. Please know what you are doing. May need STMP knowledge. The lowest bidder gets the job. I do not care if you have 1 million positive completed jobs. The lowest bidder will get the job. This is what I need:

First name

Last name

Address

City

State

Zip

Phone: ( Area code and number)

Date of Birth:

Division:(Adults/Juniors)

NTRP: (1.0,1.5,2.0,2.5,3.0,3.5,4.0,4.5,5.0,5.5,6)

Sex: M/F

Region: (Southeast,Northeast,Southwest,Northwest)

Captcha

Submit

Taidot: HTML, PHP, verkkosivujen suunnittelu

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Tietoa työnantajasta:
( 0 arvostelua ) United States

Projektin tunnus: #4254161

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

sonuinfy

Please check PMB for more info.

$30 USD 1 päivässä
(520 arvostelua)
8.9
imwebdesigner

I can write php code for form as per your list.

$30 USD 1 päivässä
(452 arvostelua)
7.9
neelwt4u

Please check the pmb. With best regards

$30 USD 1 päivässä
(348 arvostelua)
7.5
samkaranja

Ready for service, Quality work guaranteed

$30 USD 1 päivässä
(86 arvostelua)
7.2
freeworks

Hi, I saw your project description. I will do that oin couple of hours. Please check my profile and portfolio. Thanks

$30 USD 0 päivässä
(224 arvostelua)
7.2
jsinfoway

Hi, Have Gone through your details. We have left a PMB for you plz have a look over there. Thnx Jay JS Infoway Team

$250 USD 10 päivässä
(165 arvostelua)
7.1
natgeo

Will be done straightaway. Best price in PM.

$30 USD 0 päivässä
(155 arvostelua)
7.3
webn

I've experience working with SMTP. Need to see the your site.

$35 USD 1 päivässä
(106 arvostelua)
6.8
WEBOWEB

hello sir ready to do it lets start now and i will deliver you in few hours back please see PM regards

$30 USD 0 päivässä
(144 arvostelua)
6.9
sunil8986

REady to start.

$50 USD 1 päivässä
(184 arvostelua)
6.7
stevebryant

Hi, I can work that form. Ready to start.

$30 USD 1 päivässä
(419 arvostelua)
6.5
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

$50 USD 1 päivässä
(85 arvostelua)
6.7
nbcrony

Please check PMB

$100 USD 3 päivässä
(45 arvostelua)
6.4
realimaginations

Ready to work. see previous work samples to pm.

$30 USD 1 päivässä
(106 arvostelua)
6.1
maniya15

Ready to start..

$30 USD 1 päivässä
(134 arvostelua)
6.2
abhiramgantyada

Hi, Im interested in working with you. Thanks.

$30 USD 1 päivässä
(42 arvostelua)
6.1
subha

Hi! Ready to start. Thanks, Subha

$30 USD 2 päivässä
(48 arvostelua)
6.2
amin6106

Lets start, understood all the requirement, having experience of 6+ years in these type of forms.

$30 USD 0 päivässä
(73 arvostelua)
6.1
MagicIT

i can do this please check your message for best offer

$30 USD 1 päivässä
(95 arvostelua)
5.7
vw1880582vw

I am an experienced software developer and have 17 years experience working with the technologies you require.

$30 USD 1 päivässä
(35 arvostelua)
5.5