Design Contact Page

I need a contact page designed from an already existing design. Please see video below. I must have this complete with in the next 4-6 hours.I hired another Freelancer and waited 5 days and it didn't not come out well so now I'm up against a deadline to have this done in a few hours. I do no not have the original PSD's at the moment. So you will have to create the design with out the PSD's. Please watch this video for all the details: [login to view URL] The contact Us page should have the following: mailing address phone number fax number Contact Box with the following fields for the visitors to fill out. Name Email address Phone number text Message box Submit button Please see attached for design images.