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Website Design - Validation, Sound & Video

I need a basic Web page form that can be used for validating user input and doing some calculations. The page should have the following fields:
Name
Address
City
State
Zip
Telephone number
E-mail address
Date of birth
Radio buttons for credit card type
Credit card number
Credit card expiration date month
Credit card expiration date year
Input button that calls function that validates e-mail address by checking for @ sign. If no @ sign is found, display a message.

2.

Add a selection list for the state.
Add a selection list for the credit card expiration month.
Validate the credit card expiration year.
Add a mortgage calculator to the page as a value added aspect for the customer.

3.

Add a JavaScript function that loops through each input field in the form and tests for an empty string
Add input button and JavaScript function that creates cookie with form info (name, etc.)

4.
Add a sound file
Add a video file
The CreditRoll class applet: Include buttons to start and stop sound & video files - use Windows Media Player

Solution Summary

Solution gives a web page that includes input validation, javascript functions and sound/video. Attached as .zip.

$2.19