Graphic Design - Web Enabled Coupon Designer

The scope of this project is to design an interface for a simple tool that will allow a user to create their own coupons (specify it's design and it's parameters). The design should follow the attached screenshot from another page in the same web application where the user is creating interactive commercials. The same style should be used as in the screenshot. The basic flow of the user interface design will be that the user will upload an image that will meet the requirements of the application (size, format etc.) and then they will set the parameters for the coupon (its value, expiration dates, etc.) The parameters that the user has to complete in the coupon creation process will be provided. There are about 10 different fields for the user to select in the process of designing the coupon. Design direction will be provided by Boggs Systems Lead Designer. Let me know if you have any questions, and I will broadcast answers to bidders. Cheers, Jeff