Talented CSS/HTML designer for ongoing project needed

We are looking for a talented CSS/HTML designer to do a simple job that will lead to many more jobs for the selected worker. We will use this example to evaluate your HTML/CSS skills and to choose a worker for an ongoing project. The project will consist of converting a PNG example to CSS/HTML. The attached PNG([login to view URL]) is a guide to the content needed and the CSS/HTML should match as closely as possible but we understand the limits of CSS/HTML. We have also attached a sample HTML form([login to view URL]) to be used as a guide to match the look and feel for the new form. We only need the frontend CSS/HTML code, no backend code is required for this project. **You are bidding on the completing the attached PNG form only.** Markup should be compatible with IE 7+, Firefox and Chrome.