Create a form for my site

Hello all;

I currently have a site with a form that isnt working, this is a simple fix to the right programmer but frustrating for me, i think my frontpage is screwing it up: <[url removed, login to view]>

I would simply like to cut and paste the HTML on to mysite once this is complete and of course test it... let me break this down for you:

The form has both hidden and imputed fields and must post to a 3rd party site an email confirmation and then to a thankyou page, i also need to capture the IP and date and time:

## Deliverables

Form Name: Suppliers_Insert_DynamicRealTimeLeadsLead

**URL for HTTP Get and HTTP Post**

_[url removed, login to view]

Thankyou page: <[url removed, login to view]>

Here is what the end result from the input/ hidden fields must look like:

**SupplierID:** 11374

**SupplierPassword:** idf8df56dek

**firstname: ** test

**lastname:** test


**City:** test

**state:** MT


**phone1:** 4444444444

**phone2:** 3333333333


**EmailAddress:** someonesemail



IPAddress:** [url removed, login to view]



Everthing that u see above must carry as a field but only the ones that have test or a value after it are a required input (i want the customer to see), supplier id and password are hidden and constant.. For a better view of the form visit my site at: [[url removed, login to view]][1] oh yes and the "state" field is a drop down menue for 2 character abreviations.

If u can fix my problem with the form on my site you are more than welcome too, i have used front page and it wont post to the url of my supplier, etc.. this may save u time, i will still pay top dollar for the fix as it probably easy for u and a nightmare for me.

I would like to thank you in advance for your help, and for your promptness in this matter, email me if u have anymore questions or need clarification.


1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done.

2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables):

a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment.

b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request.

3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement).

## Platform

I would like this to work with my fronpage extensions but this maybe the problem in the begining. I can email u a file that the lead company i supply sent me to walk me through this, it may help but everything is outlined above

Habilidades: PHP

Veja mais: web programmer for hire, want to hire a programmer, want a coder for a company, u break i fix, test hire programmer, programmer test questions, programmer for web sites, party city com, one dollar site, oh law, need programmer to create software for me, html programmer for hire, hire programmer for one problem, hire programmer apps, hire a programmer to create a software, hire a programmer for your site, hire a date, help me with my password, get programmer to look at your code, get help from a programmer, get a supplier, get a coder programmer, get a coder problem, get a coder down, dollar everything

Acerca do Empregador:
( 6 comentários ) Canada

ID do Projeto: #2990654

Concedido a:


See private message.

$63.75 USD em 2 dias
(60 Comentários)

7 freelancers estão ofertando em média $70 para esse trabalho


See private message.

$42.5 USD in 2 dias
(216 Comentários)

See private message.

$85 USD in 2 dias
(11 Comentários)

See private message.

$76.5 USD in 2 dias
(8 Comentários)

See private message.

$85 USD in 2 dias
(9 Comentários)

See private message.

$63.75 USD in 2 dias
(6 Comentários)

See private message.

$76.5 USD in 2 dias
(0 Comentários)