Data Input Application

This is for a Windows based platform, it can be a java application, windows appliation, it does not matter. I would like to have data entry fields for input as per below. 1. First Name 2. Last Name 3. Wedding Date (Drop down for month day year) 4. E-mail Address 5. Phone Number 6. Mailing Address (with drop down for Canadaian Cities & Provinces) 7. List of item they are interested in ( I will provide a list of about 3-4 items from a drop down list, able to select multiple) 8. Customizable message somewhere on the input box (similar to accept conditions and terms. 9. Would like the input box to be customized a little with the my logo ( i have a designed logo) and the items being out up for a draw. 10. Comments section. 11. The ability to make certain input fields as required. The cutomization to the dialogue box should be configured via ini file of some sort. Validation on the e-mail, phone number xxx-xxx-xxxx, and basic validation. Further details can be discussed. The output should be a CSV coma delimited file. ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). * * *This broadcast message was sent to all bidders on Thursday Aug 16, 2007 1:41:26 PM: Thank You for you interest, I have selected a bid from one of the coders, not the cheapest but the decision was based on qualifications and other factors. ## Platform Windows XP