Set up the following optin box

I want the optin form you see on the following design set up: [login to view URL] I?ll send you the PSD and the template for you to do your thing. If you have the skills I?d like to hear from you for this project and upcoming projects. VERY IMPORTANT: Reply reliable and fast coders with a professional portfolio and good communication skills ONLY. ENSURE you submit prior examples of this sort of work with your bid.