Simple asp contact form

In Progress

Hello,

I am looking for somebody to create a simple contact form and have the information send to my e-mail address.

My website is hosted through Microsoft Office live websites so it needs to be done using ASP. I think.

Please find enclosed an image with the exact contact form that I need. I will need the same exact form in two different pages on my website.

Fields are:

Practice Name:

City:

Phone:

Email:

Contact Name:

Submit

All the fields need to be validated.

I need this done as soon as possible.

Please let me know time estimate for this,

Thank you.

AFMA

Skills: .NET, ASP, Javascript, PHP, Windows Desktop

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Project ID: #442734