Design Functional Landing Page

Hello,

My website is [contacts removed by admin] I am no longer going to run an affiliate campaign....

When you click "Start Here", I would like a landing page to open in a new window, I would like it to match the look and feel of my site.

I want the landing page to be functional so when someone enters their information, it goes to my email. After they submit their information I would like the page to say something like, Thank you for taking the time to request more information, a licensed State of Florida agent will contact you within 24 hours.

* = Required Fields

Annuity Information»

First & Last Name:*

Date of Birth:* - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905190419031902190119001899189818971896189518941893189218911890

Investment Amount:* Select $25,000 or Less $25,000 - $50,000 $50,000 - $75,000 $75,000 - $100,000 $100,000 - $150,000 $150,000 - $200,000 $200,000 - $250,000 $250,000 - $300,000 $300,000 - $400,000 $400,000 - $500,000 $500,000 - $600,000 $600,000 - $700,000 $700,000 - $800,000 $800,000 - $900,000 $900,000 - $1,000,000 $1,000,000 or More, Unsure

Annuity Type & Term: Fixed Variable Index Unsure 10 Years 15 Years 20 Years 30 Years Unsure

Contact Information

Address:*

City:*

State: FL

Zip:*

Phone:*

Daytime Phone:

Best Time to Call: Select 6AM-8AM 8AM-10AM 10AM-Noon Noon-2PM 2PM-4PM 4PM-6PM 6PM-8PM 8PM-10PM

Email:*

Grafikdesign Kundenkontakte

Projekt-ID: #771093

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