298066 Need a Quick Mail Form made

******** PLEASE DO NOT BID / PM me and then dissappear for 10 hours, If you can do the work now, please bid/PM me ******** Good afternoon everyone, I need a quick email form done up in PHP or cgi with the following requirements: - Form needs to be template based for ease of adding this form to my pages. - Need to be able to add remove/fields with ease - Script will need to email user a thank you letter and me an email with all the details - I need to be able to customize the letters ie. What I want sent to user and be able to add things like [firstname] so the thank you letter is more personalized. - Need to be able to specify 2 possible outcome pages ie. a page for Error, Successful - Need an Install text provided Fields Needed on form * = Required fields: *First Name:( Text Box ) *Last Name:( Text Box ) *Social Security #: ( Text Box ) *Street Address: ( Text Box ) *City: ( Text Box ) *State: (Drop Down with all states, including one choice for "Not listed") *Zip: ( Text Box ) *Phone: ( Text Box ) Fax: ( Text Box ) *e-mail: ( Text Box ) *Date of birth: ( 3 Drop Down Boxes, One for Month, One for Day, and one for year) *Last 4 years job history: ( Text Box - Paragraph size ) *Educational background: ( Text Box - Paragraph size ) *Tell us about yourself and family? ( Text Box - Paragraph size ) *Tell us why you want this job and how much time you can dedicate? ( Text Box - Paragraph size ) *Do you give us permission to pull a criminal report when you pay the $245. Drop Down with default "--", Choices "Yes", "No" I will need this completed today, Saturday September 06, 2003. Winning bidder should be able to do this up quickly and support thier work. A working demo is required prior to payment. If you have any questions or want this job, please send me a PM and make an offer. Best offer and time frame gets the work and my feedback, budget is $5