Placeholder page with contact detail capture

The business is an email service provider. We are not live yet.

I need a placeholder page with a form that lets the customer enter their name & current email address, so that I can contact them and I need a form which lets them reserve an email address.

This data needs to be stored in a database (SQlite, MySQL?)

There will need to be some sort of barrier to automated registration by bots. I'm not keen on Captcha or anything like that. Could an RBL be used?

At the end of the day this is pre-registration only and the final registration will need paying for, which spammers will not do. I simply want to avoid having my database swamped with rubbish while at the same time not putting off any genuine customers.

The form to reserve an email address should be configurable so that I can set the domain name and a list of hard coded prefixes for the local-part of the address.

eg. "___________(at)domain(dotcom)"



These should appear as drop down options with a preview of the final address.

So, the customer enters his desired local-part in one box and then next to that box is a drop down with the prefix & domain and next to that (or under it) is a preview of how the final email address with look.

There will need to be an OK button to choose the address. There should be a confirmation pop-up with the text;

You have chosen "" as your email address.


Should the "reserve an email address" functionality be in a separate page / pop-up?

I need cross browser compatibilty.

The attached design is just a suggestion. Feel free to ignore it.

Skills: Graphic Design, HTML, MySQL, PHP, Website Design

See more: suggestion box design, customer service contact, a placeholder, drop box customer service, placeholder, detail, sqlite design, change detail, sqlite browser, local sqlite mysql, captcha appear, php cross domain, database sqlite, php mysql email capture, page genuine, php form cross domain, php contact form mysql captcha, php pop registration form, sqlite php form, pop contact box, design detail page, customer contact, button capture, pop email capture, ignore text php

About the Employer:
( 23 reviews ) Paisley, United Kingdom

Project ID: #4497530

8 freelancers are bidding on average $178 for this job


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Hi ready to start Thanks

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Time bounded Delivery. Fast and Quick Response. Quality Assured. Let's do it. Check PMB for more details.

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Our goal is to exceed the expectations of every client by offering outstanding designs, increased flexibility, greater value in development, thus optimizing system functionality and improving operation efficiency. Our More

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I'm interested. Very professional with PHP, and MySQL. Will provide an CAPTCHA system to barrier to automated system. Will provide you a simple back-end to manage your cconfigurable email address list. More detail will More

$222 USD in 3 days
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We have gone through your requirement. We are able to deliver you the best. Please have a look on our profile and portfolio. Thank you.

$164 USD in 4 days
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Hello sir, please check your private message.

$266 USD in 15 days
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i am able project very easily.

$111 USD in 7 days
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hey i can do this also i have a better solution for storing the data users submit. i currently use Google docs for most of my clients as they can login and view the data very simple and organized. also have bot prot More

$155 USD in 1 day
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