Need to code a simple php page

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Bids
10
Avg Bid (USD)
$50
Project Budget (USD)
$30 - $100

Project Description:
Hi, I need to code a simple php page as below and fix it into the design given. Attached are the details.

Skills required:
Engineering, Software Architecture, Software Testing
Additional Files: vw_2012___08___07___sap_contest_design_RAC_NameCryptedToProtectYourPrivacy_X20128772435896307067337754027680605875.zip
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