Credit App Addition To Auto Site

This could not be more simple. Here is the information I need: Full Name (Last, First, Middle) SIN# (9 digits) Date Of Birth Email Home Address City Province Postal Code Home Phone Present Employer / Type Of Business (If Self Employed) Business Phone How Long? Years / Months I GIVE THE ABOVE INFORMATION FOR THE PURPOSE OF OBTAINING CREDIT AND AUTHORIZE DEALER TO OBTAIN INFORMATION CONCENRNING ANY STATEMENTS MADE HEREIN. (Then some sort of I AGREE or confirmation button). Then the results of the form would just be sent to an email address for processing. It couldn't be easier. The only part that gets a bit creative is that I would like a nice little graphic to use on the site: NEED CREDIT? APPLY NOW FOR INSTANT CREDIT APPROVAL! Then I would need that graphic worked into various pages in our site (jsp/html/cgi pages). The job is very small but needs done ASAP. Please bid a be ready to start right away, I will accept someone before the auction ends (sooner the better). In your bid please give an estimated time to have the form complete and up and running. It should look decent and if it could follow the look / style of the rest of the site that would be great. ## 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). ## Platform Just a simple web form.