Need a Custom Order Form Template for WHMCS

Need a Custom Order Form Template for WHMCS

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Job Description

Need a Custom Order Form Template for my WHMCS installation

requirements are here

https://docs.google.com/document/d/18nvtbU5OG1FQHeHncAe3-iBXIv8KAXcGz5BeM3ZshyM/edit

let me know what do you think

BUDGET CAN BE DISCUSSED