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

Discussion in 'PHP' started by FlakDevelopment, Aug 14, 2008.

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  1. #1
    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!
     
    FlakDevelopment, Aug 14, 2008 IP
  2. FlakDevelopment

    FlakDevelopment Banned

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    #2
    found someone. thread closed.
     
    FlakDevelopment, Aug 14, 2008 IP
  3. EricBruggema

    EricBruggema Well-Known Member

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    #3
    Tolate.

    :)
     
    EricBruggema, Aug 14, 2008 IP
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