In Progress

WEB 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: #1290416

12 freelancers are bidding on average $155 for this job

toinnisfree

pls chk pmb

$150 USD in 4 days
(610 Reviews)
8.1
epark

Dear Hiring Manager , Good Day I’m interested in the position of "Word Press" you recently posted.please check pm.

$200 USD in 5 days
(201 Reviews)
7.2
seospider

i am interested

$200 USD in 5 days
(51 Reviews)
6.3
gutenmorgen11

Hi. I'm ready to start. Please check PM.

$150 USD in 7 days
(26 Reviews)
4.4
jobdonerite

Hello, If are able to provide your server access details ASAP and your database is already configured correctly, I can deliver the form you need in 1 day for 70 USD.

$70 USD in 1 day
(1 Review)
2.7
infosolz123

Hi We have a good and experianced wordpress developer. we already developed lot of wordpress site. please check the few link which we developed in wordpress. http://readysolution.info/sigma/ http://readysolution.i More

$200 USD in 5 days
(4 Reviews)
3.5
giorgioferroli

can do it now for you sir, please check pm. have experience in php mysql html css

$110 USD in 1 day
(1 Review)
2.1
aman24659

Please check my PM.

$200 USD in 2 days
(0 Reviews)
0.0
dalker

Ready to start.

$140 USD in 4 days
(0 Reviews)
0.0
khannasaransh

Please check PMB

$150 USD in 1 day
(0 Reviews)
0.0
jtechnepalnew

Pls check pm.

$200 USD in 3 days
(0 Reviews)
0.0
selcukb85

I have graduated computer engineering,im working now looking for extra job,if you give me time i will be pleasure to do this job for you.I care experience and planning to advance in freelance together with my own offic More

$90 USD in 7 days
(0 Reviews)
0.0