5 tier membership sign up page

I need a 5 tier membership sign up page for a web site already up on line with payments to a paypal link.

[login to view URL] Home Page

Please look it over and let me know how much it will take in hours to complete it.

Pureharlem Registration Page on [login to view URL] Home Page

Include Name & Email, & Age (make these mandatory to submit to sign up.)

*Name_________________________________ *Age_________

*Email_________________________ (Email to be verified)

Address_________________________________________

City____________________________ State__________

Zip______________ Phone_______________________

Referral Code[ ] (Box to place 6 numbers)

(All are NOT mandatory to click through to sign up except *Name & *Email, & *AGE.)

Referral Code is a box where the signup can put a number based on who referred them to Pure Harlem

MEMBERSHIP LEVELS:

One month recurring payment and One time Annual payment with check boxes

[ ] Honorary (Approved by Administration)

[ ] Platinum $100. Monthly) $1,000. Annually

[ ] Gold ($60. Monthly ) $500. Annually

[ ]Business ($60. Monthly ) $350. Annually

[ ]General Membership (FREE)

The check boxes go to a PayPal payment page for the desired payment once they hit the submit button.

*(Mandatory to check box for Membership click through)

* [ ] I agree with the Terms of Use and Privacy Policy [hotlink these two pages to the links below ]

TERMS LINK [login to view URL]

PRIVACY LINK [login to view URL]

Please enter image "code box".

[ submit button }

Kĩ năng: Thiết kế trang web, PHP, HTML, Thiết kế đồ họa, eCommerce

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ID dự án: #27587034