27315 Easy Opt-In Script

I want a script which will do the following: 1. [login to view URL] (Main Page) will collect basic data from user such as Name, Address, Phone Number, E-mail Address, and IP Address. 2. Once Info is entered user will click Verify Button which triggers an email to the user. 3. The user clicks a link in the email and is then directed to a welcome page. 4. A database record needs to be made of all opt-in users with access to the data via a web-based admin. This can be a flat-file database or mysql whichever is easire. 5. I must be able to edit the html on the pages easily and edit the email verification text easily. 6. Note: No Opt-Out routine is required but if it is available, that's OK too. Timeline: completion within 2 days of accepting offer. Payment: via Scriptlance Escrow (See my rating, I Pay fast upon satisfactory completion.