Hi There, I am a Senior Salesforce Admin, Consultant, and Developer with 7+ years of experience in Salesforce. I am a highly trained Salesforce certified with a strong knowledge of Salesforce Architecture, Design, and Development along with experience in Salesforce configuration and customization.
I have checked the attached document carefully, I will surely help you in this regard. I can create a window similar to your current window and it will include the First Name*, Last Name*, Email*, Primary Affiliation Search window, Self-Identified company, and Address (*=required).
I have good experience in creating custom objects, Fields, Page layouts and related lists, Configuration validation rules, Workflow rules and approvals, Process builder, and writing Apex and Visualforce code.
Do let me know if I can work with you in any case related to it.
Kind Regards,
Piyush Singhal