Simple PHP Submission Form

Budget R210 - R1750 ZAR
Bids 45
Average Bid R925

I Need a simple PHP submission form that will allow users to place orders for either a Cartridge OR Paper
Upon submission the form will need to insert these entries into a mysql table

Fields should be

(1)User Detail

User Name: (Str field)
Full Name: (Str Field)
Cell No: (reg expression verification)
Email: (verify if email is valid)
Location: (String field)

(2)Device Detail

Serial Number: (String Field) - Should have the ajax function to lookup the model of the device, if serial does not exist in table it should be added
Model:(String field)
Meter Reading:(Integer field)
Current Supply Level: (String Field)

(3)Order Detail
Paper: (Radio Button (Yes/No) - If Yes, a new field should appear with a quantity field)
Cartridge(Radio Button(Yes/No)

Image Verification(Captcha)

Submit Button

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  • jeteon Profile Picture


    Soweto,  South Africa

    Engineering has taught me the value of assessing client needs and designing solutions to help them do what they do more easily and effectively. Please allow me to show you the value of a solution engineered for you.

    PHP, Javascript, Python, and Matlab & Mathematica

  • visionintl89 Profile Picture


    peshawar,  Pakistan

    Problem is a way to sucess

    PHP, C Programming, Java, and Javascript

  • dearphp Profile Picture


    Mumbai,  India

    I have ~5 years exprience of web developement and team lead. I have developed 70+ websites in core PHP, OOPs concept, MVC Structure, CodeIgniter, MySQL, AJAX, JS, Jqeury, APIs, JSON, HTML, CSS, Web2.0 and readymade open source scripts like Opencart, CREloaded, OS-commerce, Magento, vBulletin, PHPBB, Mambo, X-cart, Zencart etc.I can actively work and use my skills for growth of self and clients company. I will Provide Quality Work and make my clients happy...! I will do my best... (Hardworker & 100hrs availability in a week... :-) )

    Javascript, XML, AJAX, and Joomla

  • codehard Profile Picture


    DOHA,  Qatar

    We are Team of 30+ Coders and Designers who are Experts in Magento , Joomla , Wordpress , Drupal , HTHML 5 . We have more then 9 years experience under our belt . Rest Assured you are in good hands once we are Hired . Our key clientele includes companies from US, UK, Australia, Singapore and Denmark etc.. almost from all over the globe hence capturing international market. Our rates are very cheap in comparison to other outsourcing companies but it doesn't mean that we compromise on quality. After sales service is one of the strongest offering at CodeHard., which includes regular follow-ups and continuing online support to our clients.

    PHP, Perl, Javascript, and Cold Fusion

  • Bindu9057 Profile Picture


    Dhaka,  Bangladesh

    This is me Bindu Hasan .A Bangladeshi freelancer working good job for good money.

    PHP, C Programming, Data Processing, and Data Entry

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    Piatra Neamt,  Romania

    C/C++/PHP programmer and Web developer Zend Certified Engineer PHP 5.3 from 2013

    PHP, C Programming, Java, and Javascript

  • WebBizSolution Profile Picture


    Glasgow,  United Kingdom

    We offer perfect solutions tailored to meet your style and needs. We go for solutions that bring you on top and an edge over your competitors. With an extensive range of services that suits your needs, we are there to give professional assistance .

    PHP, XML, Website Design, and Logo Design

  • amin6106 Profile Picture


    Karachi,  Pakistan

    Love to create new web based projects, using technology to stream line businesses

    PHP, ASP, Javascript, and Script Install

  • gatiworks Profile Picture


    Delhi,  India

    ## BIO PHP MySQL .Net C# Java HTML CSS Joomla OsCommerce Wordpress OpenCart Drupal Android Programming Mobile Programming ## Area of Expertise PHP MySQL .Net C# Java HTML CSS Joomla OsCommerce Wordpress OpenCart Drupal Android Programming Mobile Programming

    PHP, Java, JSP, and Javascript

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    Bloemfontein,  South Africa

    ## BIO Several years experience in software development and management. Programming languages: C# SQL PHP JavaScript HTML VB6 ## Area of Expertise Windows Linux OSX Software Development Database management Project planning PHP, Javascript, MySQL, SQL Server

    PHP, .NET, Website Design, and Logo Design