Auto Loan website application and database for each state

Hi, I would like an auto loan wesite, application form and database. The website /application form and database should allow website users to select a state in the usa.. by clicking on a map of the usa and then a form will show up and they can enter there first name, last name, phone number, email address and zip code then select apply now! (button) and that information should be sent to the database and saved under that state and zipcode.. for later search to allow to sell that lead to dealers by state and zipcode... then a full application form should be on a third page and the first set of information should be already filled in and then a complete form will be filled out with more questions and then another submit button will be clicked and a full list of information will be sent to the database for later search by state and zipcode... then later be able to search by state and zipcode to pull that information and extraact it as a lead to sell to dealers.... Also if there is a way to make a backend admin section for dealers to login and selelct leads by state and zipcode for purchase and download leads or just an admin section where i can login and view and download leads in a nice format where I can have a company logo and format.. then i can fax, email them to dealers. Even a portal admin website where I can select a state and or zipcode to view and select leads from the database to assign to dealers and they can login and view the leads and print them from there... If you have experience in this and have done this for someone else please give me info so I may see a demo.. I need this asap...