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Visit http://bit.ly/W9Yt8r. Once you visit above link, click on "Product Category" dropdown from here i want the same stuff as it is there is no change it may be select menu (or) a textbox but once user selects the data should be filled in that. Once user submits email will go to admin.
Attached is plain/sample html. Please note the categories will be added dynamic from database.
Preferred bids who can deliver in 2hours. Fixed budget is 30$.