Contest Need a quick graphic for an email printable form $10 fast paypal

I need a creative graphic designed for me to get email addresses from my customers at my local store.
This will be a mini form they fill out by hand.
I want it to say

Join our email list for updates, specials, exclusive discounts, and much more
Name______________
Email______________
Phone______________
Box where they can check Please add me to your weekly email newsletter

Here are the specs
Full Bleed Size 4.33" x 5.59" 110mm x 142mm 1300 x 1677 pixels Document Trim Size 4.21" x 5.47" 107mm x 139mm 1264 x 1642 pixels

Also here are few image ideas

http://tinyurl.com/422yl2l
http://tinyurl.com/3v26el8
http://bsed.org/images/email.gif
http://www.finewinetrio.com/Graphics/EmailIcon.gif

please try to use two images you think will look good, doesn't have to be these

Thanks
JC 

 

Is it still open? No entry so far...

 

Yes still open. Thanks

 

Here is my try:



I try to make it simple and clean.  Let me know if you want to add your Logo and/or your Store name.  Feedback appreciated.

Thank you. 

 

entry sent via PM

 

can I see with updates, specials   on the same line

plus maybe another font

Thanks 

 

Thanks for your invitation...
Comments are appreciated
  

 

Thanks for the feedback, here is the revision:



thank you. 

 

Trimmed size... final file available with 7mm bleed on all edges...

 

Hi  Can you change Phone to Mobile #

and add another check box at the bottom saying Please add me to your SMS Text Alerts 

 

Here's my entry 

 

 

Font size revised as requested....