Cancelled

FORM DEVELOPER

We require the following form designed for a website currently using wordpress theme in PHP coding.

Form Requirement

* means required field

1. Form Pg. 1

a. Required Fields

i. First Name*

ii. Middle Initial

iii. Last Name*

iv. Email Address*

v. Primary Number*

vi. Secondary Phone Number

b. Continue Button

2. Form Page 2 (SSL Required)

a. Required Fields

i. Card Type (Visa, Amex, Mastercard, Discover) (radio button)*

ii. Card Number*

iii. Expiration Date (Dropdown Menu for Month & Year)*

iv. Security Code (3-4 characters max)*

v. Name on Card*

vi. Billing Address*

vii. Apt/Suite #

viii. City*

ix. State (Dropdown Menu of all US States & Territories)*

x. Zip*

xi. Select Service: Credit Repair Inquiry Removal (Radio button)*

b. Continue Button

3. Based on the Service Selected the Forms will differ:

a. If Credit Repair Select on Form Page 2 then: (SSL Required)

i. Required Fields:

1. Physical Street Address*(Should be prefilled from previous form)

2. Apt/Suite# (Should be prefilled from previous form)

3. City* (Should be prefilled from previous form)

4. State* (Should be prefilled from previous form)

5. Zip* (Should be prefilled from previous form)

6. Date of Birth* (Drop Down for Month, Day, and Year)

7. Social Security Number (3 Text boxed with dashes between them for example 555-55-5555 for a maximum of 9 digits separated by 3-2-3 digits.

ii. CONTINUE Button

4. This is the Accounts Listing Form:

a. Required Fields:

i. Creditor Name

ii. Account Number

iii. Reason for Deletion (Drop Down Menu)

1. Not My Account

2. Never Late

3. Wrong Balance

4. Paid in Full

5. Included in Bankruptcy

iv. Repeat these 3 fields with all 3 in a row horizontally going down to 35 accounts that can be listed for removal.

b. DISPUTE NOW Button

5. This will lead to Preview Page

a. This page should show an outline of all information provided to us.

i. Required Fields

1. First Name, Middle Initial, Last Name

2. Physical Address, Apt/Ste/#, City, State Zip

3. Date of Birth

4. Social Security Number

5. Primary Phone Number

6. Email Address

7. List All Accounts Provided, Account Numbers, and Reason for Removal

ii. These should be a display page and all above fields should NOT be shown in text boxes.

b. 2 Options

i. Revise or Correct Errors Button which will allow user to goto a page to correct any of these fields shown

ii. Submit Dispute Now Button

6. If DISPUTE NOW Button is Selected then

a. Should show a Confirmation Page with all the following field shown:

i. Required Fields

1. First Name, Middle Initial, Last Name

2. Physical Address, Apt/Ste/#, City, State Zip

3. Date of Birth

4. Social Security Number

5. Primary Phone Number

6. Email Address

7. List All Accounts Provided, Account Numbers, and Reason for Removal

ii. And a statement from us about how long the process will take at the very bottom of the page.

b. At this point all data should be secured in the database and Admin should be able to get required fields emailed to him and be able to access them using an admin panel.

• IF during Form Page 2 the Inquiry Removal Option was Selected then:

o Should goto (SSL page) with Required Fields:

 First, Middle Initial, Last Name (Pre-filled in text box from previous form)*

 Physical Street Address*(Pre-filled in text box from previous form)

 Apt/Suite# (Pre-filled in text box from previous form)

 City* (Pre-filled in text box from previous form)

 State* (Pre-filled in text box from previous form)

 Zip* (Pre-filled in text box from previous form)

 Social Security Number*

 Date of Birth*

 Name of Creditor* Date of Inquiry*

Address of Creditor*, City, State(Dropdown), Zip Code

• (All The green colored fields should be repeated 10 times to allow user to list up to 10 inquiry accounts.

o DISPUTE INQUIRIES NOW Button

• Preview Page: This leads to the preview page where they see all above fields in NON-textbox form just print form.

o They have option to Revise or Submit Inquiry Removal

• Confirmation Page:

o Print out of all Blue and Gree

Skills: Electronic Forms, PHP, Software Architecture

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About the Employer:
( 4 reviews ) Beverly Hills, United States

Project ID: #1289485

13 freelancers are bidding on average $329 for this job

psenthilkumar

Hi, Expert Here! Seen the attachment & Got Your Requirements :) Will provide you all fields in form with UNIQUE & ATTRACTIVE DESIGN suitable fro your current WordPress theme :) Please check inbox!

$250 USD in 2 days
(158 Reviews)
7.6
exactprecisions

I have years experience in web development and design. I am a professional who will pay attention to details, give you a great experience, good communication and on time! Let me know if you have any questions. More

$250 USD in 7 days
(105 Reviews)
6.9
rosew100

Hi, I have wordpress expertise together with php, javascript, jquery. I can design and develop forms for you according to your requirements. please let me know. thanks

$550 USD in 3 days
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6.7
LuigiWidmore

Hi sir , My name is Luigi Widmore and i'm an expert web developer. My areas are HTML/CSS PHP/MYSQL Design/Photoshop. Please check PM for details , you may be impressed. Thank you

$250 USD in 999 days
(101 Reviews)
6.4
freeworks

hi,i saw your project description. I will do that on time. I will do custom design and coding for you. Please check my profile and [url removed, login to view]

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6.4
MaximSky

Ready to implement listed forms into your website.

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SALowell

Hi. I'm an expert when it comes to form work (dynamic forms, posting and retrieving form data, form data validation, etc.) and I would love to work on this project.

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spykecoders

********************************************.. YOUR SEARCH ENDS HERE .. ********************************************** GET IT DONE RIGHT THE FIRST TIME! Hello There, I look forward to talking to you further and getting More

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nileshbakotiya

Hi ready to start Thanks

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fchakkara

Please check pm for details.

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sharma1083

Hi, please check inbox for [url removed, login to view]

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infotechwiz

I can develop a bug free and high quality form for your website. Accept my bid now!

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khannasaransh

Please check PMB

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Mmonyango

I am an expert in PHP,C++,.NET,JAVA,VFP9 and databases MSSQL,MYSQL and web-design in Dreamweaver CS5, wordpress. I have developed a large application for microfinance which was reviewed by WorldBank CGAP see SML VISIO More

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