Contest I Need 2 Opt-in Box Design NO Coding $25 Pay out..Easy Money!

I will provide Immediate Feedback to give you the best chance of making a good design.

* I PAYOUT Instantly Upon Receiving Designs
* I Give constant Feedback to increase your chances of creating winning designs.

I am looking for a designer that can create a full width and single column sidebar opt-in box.

Needed:
Single Column Opt-Box With Autoresponder coding 320px by 117px
Add icons in form fields so user knows what the form represents
Form Fields: First Name Last Name (Two fields on one row)
Email Address
Mobile Phone
(Check box) I would like to receive sms/voice message reminders
for the Webinar and Exclusinve VIP information and events.
Country (Dropdown list)
City (Two fields on one row)

Examples of Designs Needed:
Sidebar Optin: http://img233.imageshack.us/img233/4838/homelogin2.png
Quality of Designs Needed
http://dribbble.com/shots/344627-Sign-In?list=searches&tag=form_fields
http://dribbble.com/shots/558119-Contact-form?list=searches&tag=form_fields
(use tooltips from the above example)
http://dribbble.com/shots/850194-Form-And-Autosuggest?list=searches&tag=form_fields

Style/Colors Variations:
1. Dark Blue with Yellow "Get Instant Access" Button with red text
2. Red with Orange "Get Instant Access" Button with red text

Opt-in Box Header Text: Register Today For Your Life Changing Webinar!

Opt-in Box Text Above the boxes: Enter your details and learn how to Take Your Vision to Fortune 500 Successby usine Next Level strategies.
(bolded text is bolded on opt-in header)

Privacy Statement: I respect your privacy and have Zero Tolerance for spam. Your Information is safe and secure with me. (image of a lock would be perfect)

Time: 48 Hours or until design concept is accepted.

Submit: PM or Forum, Your Choice

 

please wait me

 

Hi,
I don't understand mean....

1. Dark Blue with Yellow "Get Instant Access" Button with red text
2. Red with Orange "Get Instant Access" Button with red text

these colors combination button not looking graceful. pls reply
Thanks
Regards

 

My Design, Feedback Appreciated

 

My try:


With pattern on the background:

 

I'd like the button bigger and in the middle like this image with the handdrawn arrows pointing to it.
http://img233.imageshack.us/img233/4838/homelogin2.png

1. The text at the top needs t be centered
2. Make the form fields more square than round
3. Use this iconset for icons in form fields http://www.icondeposit.com/theicondeposit:108
4. For country use globe and for city use the map pin.
5. Put a title with big letters that says Register For Our Webinar
6. At bottom put visa, mastercard, discover, american express and paypal logos

 

What size do you need?

 

Here is a good example of the size I need:
www.startupsdirect.com
but with the fields i specified

 

Revision:

 

1. Change color of black box to something eye catching. This should be a headline that says REGISTER NOW FOR OUR LIVE WEBINAR EVENT
2. Text in black should go above form in place of Register Today text
3. Next to the check box should be a chat icon with the word SMS inside
4. Make arrows more refined and less curve
5. Center payment icons
6. Also use this color red
http://www.inreality.com/images/5-5-0-webinars/2011/11/29/5-5-1_webinar_event_021_banner.png

 

here is my try, feedback appreciated.


No icons is used as i wasn't able to download tht given icon pack.

 

My Revision, Feedback Appriciated....




Any Changes require.. Pls reply