PeoplesProgram Capture Page

This project received 5 bids from talented freelancers with an average bid price of $97 USD.

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I need a capture page that will outperform the existing page. Need to capture name, email, phone, and drop down menu for the source of the lead.
My current capture page is at I have a photo that I want you to incorporate into the page and also make it where I can add videos and other stuff to the source code.

The picture I'm sending is for a post card. I will be sending the actual digital photo in a couple of days.

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