Form Validation

Hello,

I need a HTML form designing. the form will be to help solve voucher code problems. Depending on what they select will depend on the page they will see with the advice given. For example I need something that asks for the date they purchased it. If it’s more than 1 month old it needs to tell them its expired. I need other options for solving problems such as what city the deal was purchased in. The form would then take info and email. Any takers?

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