Php Form Needed

I need a form that allows me to display the company name, email, phone, web address and phone number of the listing. In addition I need when the form to capture a screenshot of the website to create an auto thumbnail in the listing using thumbshots(dot)com

The listing page should display up to 25 results at a time before the user has to click on the arrow to see additional results. At the top of the listing page there should be a search selection for the user to beable to select the viewable …

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