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Payment notice script (E-Mail form)

I'm a hosting provider and need a payment notice script.

Here's what I want:

1). Informations will send to my E-mail box.

2). Three pages.

3). A simple neat template.

First page includes:

1). Customer's name. (No need to separate First & last)

2). Contact E-Mail.

3). Choose a packge. (Drop down)

4). Telegraphic transfer or paypal. (Cheek box)

5). If chosed telegraphic enter your account's last 5 numbers.

6). If chosed paypal enter your paypal account.

7). Payment date, time and ammount.

Cheek: ALL FORMS MUST BE FILLED!!

NEXT>>

Second page includes:

1). Username your want. (Max 6 letters)

2). Password your want. (Re-enter)

3). Use my domain or plaese give me a free one. (Cheek box)

4). Enter the domain for your account.

5). Use our free domain. ([url removed, login to view])

Cheek: ALL FORMS MUST BE FILLED!!

SUBMINT>>

List all the informations.

Put a "Go back and edit to both pages" buton, Send.

There will be changes, I need this script within 2 days.

There's a worng place, should be:There will be NO changes, I need this script within 2 days.

Plaese add a Note column in both pages.

Compétences : PHP

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Concernant l'employeur :
( 77 commentaires ) Taipei, Taiwan

N° du projet : #19160

Décerné à :

Kaabi

Hello Sir , this script can be done within 3-4 hours

50 $ USD en 0 jours
(28 Commentaires)
4.5

10 freelancers are bidding on average $63 for this job

jobonline

Hi, let me get it done Quickly! regards

60 $ USD en 2 jours
(56 Commentaires)
6.5
harryg

Please see PM for details of my bid

50 $ USD en 1 jour
(58 Commentaires)
5.2
avissoft

Hi, I can do the job for you in just 1 day as you have specified. Thanks.

30 $ USD en 1 jour
(15 Commentaires)
4.2
softsolin

hi, get it done in few hours, regards, ashish

30 $ USD en 0 jours
(7 Commentaires)
3.5
admont

I can do it quickly, qualitative and secure

50 $ USD en 1 jour
(1 Commentaire)
1.0
ubckevin

i can help. please see pmb for details.

100 $ USD en 2 jours
(0 Commentaires)
1.7
namirtha

We have 6 years of experience in developing web based application using PHP/ASP/.NET and Java. We are highly interested and confident in developing the email templates to meet your needs. Please feel free to contact me Plus

100 $ USD en 10 jours
(0 Commentaires)
0.0
Radek28

Hello, I will be glad to make the script for you. Regards, Radek.

80 $ USD en 2 jours
(0 Commentaires)
0.0
mywebproviders

I can do this for you. Please see PMB for demo and questions.

75 $ USD en 0 jours
(0 Commentaires)
1.0