A registration form is required

Good afternoon, colleagues.
Web programmer services are required. There is a task to program the registration form.
At the moment it looks like this: Text hidden

What you want to get on the functionality is written in TZ (file in the attache)
A new form in the attachment.

Before evaluating the project, please carefully study the TK, the current registration form and the new form!
If you have questions, ask them.
Please indicate the cost without an adaptor.