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simple forms on my site needs to be made

I must get this done today as it is important to get this on there. What is needed is very simple but I do not have the time for it. I need a form on my webpage that will send some information a customer enters to my email address

What is needed is simple and it will be for [url removed, login to view]

Now don't think it can just be some ugly form it must look nice and I do have images of my business logo that should be added in if possible. The information needed will be.

Noted on the form or page must have it to where all fields must be entered for us to verify you are who you are etc....

Full Name




Zip Code

Home Phone Number

Cell Phone Number

Best time to contact

Mortgage Amount

Current interest rate

Monthly Payment

If we can guarantee savings of $50,000 to $100,000 or more would you be interested in watching a 5 minute video about our company? (yes,No)

If we were able to show you these huge savings and have it to where there is no money out of pocket to get started would you be interested?(yes,no)

If we saved you even more money simply by you referring friends family and co-workers to simply fill this out also to see how much we can save them on their loan would you be interested(yes,no)

Would you like us to call you or email you the results?

How did you find us?

Make sure each and every question is answered and all forms are filled out. Please double check because if something is missing this form will not be sent to keep fake submissions down to a minimum as this Savings Analysis reg costs $35.00 each and for a short time it is completely free.

Included in the Free Savings Analysis will come complete graphs current payment tables and about 10 other pages showing how we will save you money and how much. This huge analysis is free for now so take advantage of it.

I need something like that now what do you got?

Apparantly I wasn't specific enough here you go

the form that is needed must have a nice professional look and design to it.

On the form

-Mr/Mrs or Mr and Mrs (as in if it is just one person or a husband and wife)
-Full Name
-Full Name
-state(this will be a drop down will all states)
-Home Phone
-Cell Phone
-Best time to call (drop down list morning noon night)
-Original Mortgage Amount
-Interest Rate
-Monthly payment

Questionaire portion of the form

-If we can save you $50,000 to $100,000 or more on your mortgage would you be interested in hearing more information? Yes/No

-When you sign up and save your thousands of dollars on your mortgage would you be willing to tell your friends and family about this service so they can save money also? yes/no

-If we offered this with no out of pocket expenses would you be interested yes/no

-Are you a self motivated person who may be interested in educating other home owners and joining our team? Yes/No

Click Submit

All questions and fields must be entered for this form to be sent.

I would like this form to be a complete webpage as in not just some cheap frontpage form. It needs to have my logo on it and the form and the entire page must have the same color scheme to it. Top of the page will read

Average savings on most mortgages through our company is $50,000 to $100,000 fill out the survey below to see how much we can save you on your mortgage payments.

All coders from the u.s.a will get better odds on getting the job as I can actually understand what they are saying and it is the best country in the world.

Evner: Perl, Script Installering, Web Design

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Om arbejdsgiveren:
( 1 bedømmelse ) fresno, United States

Projekt ID: #27900

Tildelt til:


I can do this for you right now... All fields in form will be validated before form can be submitted. Form will have a professional look to it.

$30 USD in 0 dage
(0 bedømmelser)

5 freelancere byder i gennemsnit $55 på dette job


In 50 USD i can create you an online form maker so that in future you can just click a few buttons to create your own form. Demo in PMB. Regards

$50 USD på 1 dag
(653 bedømmelser)

we surely can help u with this .pls check PMB. Regards Archana (Aught Bit Technologies)

$30 USD in 0 dage
(16 bedømmelser)

Can do it right now!

$70 USD in 0 dage
(11 bedømmelser)

I am based in NJ, USA. I have a fast response time compared to off-shore designers who usually take longer then 24-48 hours to answer requests. If you would like anymore information contact me. See PMB for portfoli Flere

$100 USD på 1 dag
(0 bedømmelser)

I would like to help you with your project I'm located in Austin Texas USA, Feel free to contact me anytime.

$45 USD in 0 dage
(0 bedømmelser)