Simple php form for website with SMTP Authentication

This project was awarded to sourov06 for $35 USD.

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$30 - $250 USD
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Project Description

I need a simple php form for my website with SMTP authentication.
The form needs to be put in the existing template of the website.
the form has four fields:

Voornaam (first name)
Achternaam, (second name)
Bedrijfsnaam (compagny name)
e-mail adres. (mail adres)

After the form is submitted its sends the contact details to a give mail adres and reguires smtp authentication.
The visitor gets a confrimation massage on the website and gets send back to the first page. and the given mail adres recieves the information.

I first like to see the lay-out of the form in an image. So i know how its going to look.

Im looking for someone who can do this task fast and not to expensive.

Thank you

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