You will recreate this device here, which will appear on my homepage:

http://www.instantslideup.com/index.php

You will customize this so that I can change its colors, fonts, wording, and appearance.

It will be ready to use with my aweber.com optin form.

It will not need to be hosted anywhere, or require paying anyone on a monthly basis.


It will work without problem on IE5 and above, as well as Firefox and Safari browsers. 

It will NOT need MySQL installation. 

It will *also* have dropdown menus for subscribers to fill in as well.  This will copy the opt-in form requirements I have on my website.