simple 20 field form -> mysql table - $25 - ASAP

I need this done asap, shouldn't take more than 30 minutes if you have dreamweaver.

FIELDS:

For the products please use a radio button. The webmaster will add it up and create a total to charge to the card. You do not need to do it.

First, middle and Last name
Social Security#/Business identity
Shpping Address
City
State
Zip
CreditcardBilling address
city
state
zip
phone
mobile
fax
email

THESE ARE RADIO BUTTONS
1 business center (2 cases) $110.00
3 business centre (6 cases) $110.00
item 2001 xocai Nuggets (One Case / 100 x 12b Nuggets $110.00
item 3001 Xocai Protein Bar (One case / 4 Boxes with 10 x 38g Bars) $110.00
item 4001 Xocai Activ (One Case / 4 x 10 oz Bottles) $110.00
item 5001 Xocai Omega Bar (Once Case/ 36 x 34g Bars) $110.00
item 7001 Xocai X Power Squares (One Case / 140 x 6g Squares) $110.00
item 8001 Xocai X Powerhouse Cookies (One Case / 40 x 57g Cookies) $110.00
item 9001 Xocai Healthy Chocolate Sample Pack ($12.50 Sample Pack Assembly) $122.50
item BBX Body by xocoloate 12 Month Subscription (No S & H Fee) $110.00
S & H Shipping/Handling ($13.50/Case*) $13.50*
*Bulk Discounts Available: 3-5 Case: $12.50/case - 6-11 Cases: $10.80/case - 12+ Cases: $9.05/case

Auto-Ship Order Request (Auto-Ship Initiates 4 Weeks After Request)
THESE ARE RADIO BUTTONS
1 business center (2 cases) $110.00
3 business centre (6 cases) $110.00
item 2001 xocai Nuggets (One Case / 100 x 12b Nuggets $110.00
item 3001 Xocai Protein Bar (One case / 4 Boxes with 10 x 38g Bars) $110.00
item 4001 Xocai Activ (One Case / 4 x 10 oz Bottles) $110.00
item 5001 Xocai Omega Bar (Once Case/ 36 x 34g Bars) $110.00
item 7001 Xocai X Power Squares (One Case / 140 x 6g Squares) $110.00
item 8001 Xocai X Powerhouse Cookies (One Case / 40 x 57g Cookies) $110.00
item 9001 Xocai Healthy Chocolate Sample Pack ($12.50 Sample Pack Assembly) $122.50
item BBX Body by xocoloate 12 Month Subscription (No S & H Fee) $110.00
S & H Shipping/Handling ($13.50/Case*) $13.50*
*Bulk Discounts Available: 3-5 Case: $12.50/case - 6-11 Cases: $10.80/case - 12+ Cases: $9.05/case



Credit Card#
CVC
EXP:
Name on Credit Card

Date Authorized

REQUIRED RADIO BUTTON
I hereby austhorize MXI Corp to charge my credit card for any order I pladce or for the amount of the Autoship order I have established. I understand that those order(s) may inude shipping fees and sales tax. In the event a charge is dishonor for any reason, I agree to pay a $20 service fee.

REQUIRED RADIO BUTTON
I have read and agree to the Term and Conditions contained on the reverse side of this document and I am familiar with the return policy described in the Company's Rules and Regulations and Policies & Procedure. I hereby agree to be bound by the Terms and Conditions, which by reference are fully incorporated into this Agreement. I certify that I am the age of majority and am legally able to enter in this Contract. I have read and agreed to the Company's Rules & Regulation and Policies & Procedures and agree to the terms and confidentiality contained therein. I UNDERSTAND THE RESALE PRODUCT PURCHASES ARE OPTIONAL.


Will pay $25 over paypal on completion. Please use my yahoo ID on my profile to contact me. Early bird gets the worm!

 

found someone. thread closed.

 

Tolate.