81315 Sign Up Form Website

I need a simple one page website that will look professional for collecting information from a potential prospect. The site may have some light flash and have the ability to sell advertising banners on it as I will add banners for my existing businesses on it. The site will generally have the following functions: 1) Display a title, description, and form(Prospect Information Fields). I need to be able to modify the content of these in the admin area. 2) Collect information of potential prospects using a form(Prospect Information Fields). This information will be directed to an email box, and the personal contact manager system. I would like to have this information secured during sign up. 3) Contact manager where I can view, edit, add, delete, or comment a potential prospect. I would also like to have a section where the name and emails can be accumulated where I can add or delete a contact as people opt out from an email list. I want to be able to easily just copy and paste them into an email together to email newsletters or a notice to that group of people. 4) An admin area so I can modify what Prospect Information Fields the site will have displayed on the sign up form. I want to be able to change the title, and the description of the website (unlimited length). I also want to be able to change the colors of the site and text, such as the title, description, and form. 5)I also want to be able to issue a mirror image of the site to another user so they can use it too to collect contacts for their business with their own independent contact manager system. Say the site is called [login to view URL], an issued site will look something like this [login to view URL] with their own independent contact manager system. I want a user name and password in order to access the contact manager system. Prospect Information Fields Name - first, middle initial, last E-Mail Address Phone (Home) Phone (Business) Phone (Cell) Phone (Fax) Best time to Call Address - leave two boxes for this under each other City Province/State Province State Zip/Postal Code Zip Postal Code Country ID/SIN ID SIN Social Insurance Number Credit Card Number -*(pull down menu of all popular cards such as Visa, Master Card, American Express, Discovery Expiry Online Check - *Proper fields for this kind of payment. All I need are the bank name, address, and numbers at bottom of check Order Start Kit - yes or no Make first 35 BP product order - yes or no Make first 39 BP product order - yes or no Make product order - yes or no Order Value Pack - yes or no Message Notes Comment I think I have everything I need listed. I will post in the meesage board if there are any changes or additions. Shawn Hinton Internet Business Manager