Landing Page Designer for Debt Leads by MichaelP77

I need a good looking landing page for gathering debt leads. Submission fields should be first name, last name, email address, debt amount, phone number, and state. I also would like the date and time the lead was submitted and the IP address in the submission info… (Budget: $30-250, Jobs: CSS, Electronic Forms, Photoshop Design, Templates, Website Design)

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