Lead Capture Page Script

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1
Avg Bid (USD)
$21
Project Budget (USD)
$30 - $100

Project Description:
I need a simple lead capture page template/script that I can use on all my websites. I have CPanel access. I want all pages(any domain) customized to go to a certain web database

I need something strong codes (bug free) that can capture people's name email address phone number etc... customized at anytime and then receive a email notification when a lead signs up and speciallfy which webpage

Congrats! You have a new sign-up.

NAME : John Doi
Email john_doi@gmail.com
Phone: 123-345-6789
Page: www.thisURL.com/leadpage

I can export it and import as csv tab delimited or whatever is the simplest way to go- into my contact manager. (not including page)

If you need more details we can chat via Yahoo for further instructions as how to proceed with this project.

Thanks and have a great day
Eterna


## Deliverables

Capture Page Template / Script



Capture all related contact info from first name to email address to phone number etc... if possible, I hope you can include where the person signed up
for tracking purpose so that i know which page was used. be sure to include today's date so it looks CURRENT all the time.

Export-able to any kind of application such as EXCEL. such as CSV etc...

The page must be easily used customizedfor me such as (font, text, design- left right center box) and keep the codes same as all data goes to a specific URL MySQL database

If you need additional question, feel free to ask me.

The example template: www.paymyloanoff.com

Thanks
Eterna

Skills required:
Computer Security, Data Entry, Engineering, MySQL, PHP, Project Management, Software Architecture, Software Testing, Web Security
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eternalist United States
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