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Simple contact form required for offline credit card payment

A Simple contact form is required for offline credit card payment processing. All this form will be required to do is receive a buyers credit card details so that offline processing is possible. It will require the following fields:

name as appears on card

card number

card type (drop down box) (visa, master card)

expiry date (mm/yy)

security code (back of card)

Address as appears on credit card statement

city

state/county/province

country

post or zip code

donation amount (drop down box) (options $10, $20, $50, $100, $200, $500, $1000)

the form should go a confirmation page on the site

the following image should be used in form:

[url removed, login to view]

Færdigheder: Elektroniske Formularer, HTML, PHP, Script Installering, Web Design

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Om arbejdsgiveren:
( 4 bedømmelser ) brisbane, Australia

Projekt-ID: #934520

9 freelancere byder i gennemsnit $38 for dette job

tania06

*************************Design with a Difference**************************

$50 AUD in 2 dage
(87 bedømmelser)
7.1
LloydesignStudio

Ready to begin. Waiting for your selection. Thanks. Lloyd

$38 AUD på 1 dag
(270 bedømmelser)
7.0
SICS

Please check PMB

$250 AUD in 3 dage
(42 bedømmelser)
6.7
exitsol

lets get started

$40 AUD in 0 dage
(124 bedømmelser)
5.9
cristisst

I can do it.

$30 AUD in 0 dage
(62 bedømmelser)
5.7
jobynexus

Ready to start. Kindly check PMB.

$30 AUD på 1 dag
(22 bedømmelser)
4.7
xzappa

please check your inbox

$50 AUD in 2 dage
(8 bedømmelser)
4.6
weboxyzendotcom

Please check PMB

$40 AUD på 1 dag
(0 bedømmelser)
0.0
dktech2008

I can design the form page for you exactly as you require. Please let me know if you have any questions.

$30 AUD på 1 dag
(0 bedømmelser)
0.0
a2zcoding

Hi, I have over 10 years experience in PHP and ASP. I can do this job easily.

$30 AUD på 1 dag
(0 bedømmelser)
0.0