Hi,
I have read all the requirements in the image you attached and assessed all of them in details. I can build your email sign up page with all the fields and design structures in the attached image. ALL CSS required will be done by me and clean codes will be used.
ALL generated data will be synced to your mailchimp account which will be developed further to accommodate all the inputs as well. I have some suggestions to make to make it work very great.
I am a fully experienced with 14 years to my credit and a specialist in full stack development /frontend and backend Development and modifications /adjustments of websites in the following platforms - MAGENTO, OPENCART, WORDPRESS, SHOPIFY, PRESTASHOP, BIGCOMMERCE, Ecommerce, Javascripts, Jquery, CRMs, PHP,SEO, SEM, SMM, speed optimizations, MYSQL , CSS3 , HTML5, Payment gateway, and many more
I am the fully experienced and very specialised for a job like yours and I am always available 16 hours daily to communicate at any time. Free Support after completion of project is negotiable.
I am looking forward for a long term working relationship.
I am ready to start now.
Thanks, Charles